The Baptist Home at Brookmeade

Based upon observation, interview, and review of facility documents, the facility did not provide a safe, functional, sanitary, and comforatable environment for residents, staff, and the public. Specifically, three of three refrigerators/freezers observed on three (B, C, and D) of three residential units were not clean and contained food items that were improperly stored, including open containers, unlabeled, undated, and outdated food items. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

The findings are:

C Unit: Observation of the C unit nourishment kitchen refrigerator/freezer was completed on 02/24/11 at 4:40 pm with the 3pm - 11 pm C unit LPN in attendance with the surveyor. The inside of the refrigerator was not clean, there were visible spots of spilled liquid scattered throughout. There were multiple food items observed in the refrigerator without name labels and without dates, there were food items that had dates written on them that were outdated. The following food items were observed in the C unit refrigerator:
a white Styrofoam bowl with another bowl on top of it (like a cover), a beige colored semi solid material was present in the lower bowl, without label and without a date
2 sandwiches wrapped in clear plastic, one was dated 02/22 and the other was dated 02/23.
a pre packaged container of fruit, without a date
3 reddish brown bowls with clear covers dated 02/23.
In the freezer were the following items:
a pre packaged box of frozen vegetables, without a name or a date
a pre packaged frozen meal, without a name or a date

An interview with the C unit LPN was completed on 02/24/11 at 4:50pm, as she was removing food items that were unlabeled, undated, or outdated from the refrigerator and freezer and disposing of them. She stated that dietary staff delivers food items to the unit such as dishes of applesauce to use during medication administration and sandwiches to serve as an alternate for dinner at the resident request. The nourishment kitchen refrigerator/freezer should contain foods for the residents, either as supplied by the facility or brought in by families. All of the foods should be labeled and dated, if the information is not on a pre packaged label. When asked if the refrigerator/freezer was checked by staff, she replied that the night shift staff should be checking the contents and remove items that are either outdated or that are not labeled and dated.

Unit D: Observation D wing refrigerator/freezer on 02/24/11 at 4:15pm revealed that there were food items that were undated and unlabeled in the refrigerator; there were multiple areas of with dried liquid that was splattered and or spilled inside the fridge and that the racks felt sticky to touch. The floor in front of the refrigerator was observed to be soiled with a blackish/brown colored area approximately 1 1/2 inches wide and the length of the refrigerator, this area was not visible when the refrigerator door was closed. The thermometer that was in the freezer had reddish brown dried liquid observed on the front area which interfered with the ability to see the temperature reading. The following food items were observed:
In the freezer: a container of ice cream, without a name label or date
In the refrigerator: a plastic container of food, without a date (was labeled with resident name and room number)

An interview with the 7am - 3pm D unit LPN on 02/24/11 at 4:25pm was conducted. She reported that the refrigerator/freezer in the nourishment kitchen was intended for resident food and drinks. The facility supplies certain items and families bring in other items that the residents may want. She identified the plastic container that was labeled with a residents name and room number as having been brought to the facility that afternoon by the residents daughter. She stated that all of the food items in the refrigerator/freezer should be dated in addition to being labeled with the resident's name. When asked about the blackish/brown area in front of the refrigerator and the splattered areas in the refrigerator, she replied that the areas needed to be cleaned. The LPN was requested to read the temperature on the thermometer located in the freezer, she identified that the thermometer was dirty and needed to be cleaned before she could accurately read the temperature.

Unit B: Observation of the B wing refrigerator/freezer located in the nourishment kitchen on the unit was completed on 02/24/11 at approximately 5:15pm with a 3pm - 11pm B unit LPN in attendance with the surveyor. The following food items were observed:
In the freezer, a baggie with 6 or 7 dark brown round items, not labeled or dated
In the fridge, a baggie with sliced white meat on the door, not labeled or dated
a white Styrofoam bowl with 2 eggs, undated and unlabeled
a bowl of readymade salad manufacturers date to use by 02/16/11, unlabeled
On the counter: a brown paper bag containing food items, without a label or date
2 plastic containers with food items, without a label or date

During the interview with the 3pm - 11 pm B unit LPN during the observation on 02/24/11 at 5:15pm, she reported that the nourishment kitchen refrigerator/freezer was for resident food items that were supplied by the facility or that family members brought in. She went on to say that all food items in the refrigerator/freezer should be dated and that those items belonging to a specific resident should also be labeled. She stated that the above listed items that were observed in the refrigerator/freezer did not appear to be consistent with items supplied by the facility and she could not tell if they belonged to residents or to staff. Some staff members do use the area to store their dinner meals on occasion. She identified the readymade salad as belonging to her and she wrote her name on the container. In the labeled with a residents name and should also be dated. When asked if any staff were responsible for checking the contents of the refrigerator/freezer, she replied that it was assigned to the 11pm - 7am shift.

The C wing (unit) 11 pm - 7 am assignment sheet dated 02/24/11 was reviewed and included that the staff member assigned to assignment 1 also had the responsibility to clean the fridge on Wednesdays and the staff member assigned to assignment 2 had the responsibility to wipe the thermometers off on Wednesday.

On 02/24/11 at 5:45 pm an interview with the Director of Nursing (DON), the housekeeping supervisor, and the administrator was completed regarding the refrigerator/freezers located in the nourishment kitchens on each unit. When asked who was responsible to clean the refrigerator/freezer located in the unit nourishment kitchens, the supervisor of housekeeping responded that the unit housekeepers were responsible to clean the kitchen, but not inside the refrigerator/freezer, the inside was done by nursing. The DON stated that the 11pm - 7am nursing staff was responsible for cleaning the refrigerator, once a week on Wednesday and should be completing nightly checks for items that are outdated or unlabeled or undated and should be disposing of those items. Each nursing unit is responsible for their own refrigerator/freezer.

During continued interview with the DON on 02/24/11 at 6:00pm, she stated that each nursing unit should include what staff member was assigned the responsibility of cleaning the refrigerator. She did not know who had the responsibility to check to ensure that it was completed. When presented with the details from the observations completed on residential units B, C, and D on a Thursday afternoon during the survey, and asked if the unit refrigerator/freezers had been cleaned during the night shift on Wednesday, she replied probably not.

10NYCRR 415.2

Based upon observation, interview, and review of facility documents, the facility did not ensure that the thermometers in the refrigerators and freezers located in the nourishment kitchen on the residential units were maintained in working order and that the temperatures were monitored daily to ensure proper storage of the food items located in the refrigerators/freezers. Specifically, the facility did not ensure that temperatures were monitored on a daily basis for three of three refrigerators/freezers observed on three (B, C, and D) of three residential units, and did not ensure that the freezer thermometer on one unit (C) was functioning, and for another unit (D) was clean enough to read the temperature gage. This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

C Unit: Observation of the C unit nourishment kitchen refrigerator/freezer was completed on 02/24/11 at 4:40 pm with the 3pm - 11 pm C unit LPN in attendance with the surveyor. The surveyor was not able to read a temperature on the thermometer located in the C Wing nourishment room freezer, the appearance of the red line was broken up and located at both ends of the temperature gage in addition to the middle of the gage. The surveyor requested that the 3pm - 11pm C unit Licensed Practical Nurse (LPN) obtain and report the temperature on the thermometer in the freezer. She was unable to read the temperature gage and stated this to the surveyor. The maintenance department supervisor was contacted by nursing.

The maintenance supervisor arrived on the unit at approximately 4:45pm with a new thermometer for the freezer. He checked the thermometer in the freezer and reported that it was not working, he then replace it with the new thermometer. When asked about the refrigerator/freezer thermometers, he reported that the maintenance department does complete monthly rounds on the units, the rounds included to check the kitchen refrigerators/freezers for preventative maintenance function, which included the checking the thermometers. He reported that the rounds were last completed on 02/17/11 and that logs of the findings are maintained in the maintenance department. He was not aware if the thermometers were checked more frequently by another department.

An interview with the C unit LPN was completed on 02/24/11 at 4:50pm, when asked if the refrigerator/freezer was checked by staff, she replied that the night shift staff should be checking the contents and remove items that are either outdated or that are not labeled and dated. She did not have information regarding checking the thermometers for function and/or temperature reading.

Unit D: Observation D wing refrigerator/freezer on 02/24/11 at 4:15pm revealed that the thermometer located in the freezer had reddish brown dried liquid on the front area which interfered with the ability of the surveyor to read the temperature. The 7am - 3pm D unit LPN was requested to provide the temperature reading for the thermometer located in the freezer, she commented that the gage area was dirty and she wiped it clean before she reported the temperature to the surveyor.

An interview with the 7am - 3pm D unit LPN on 02/24/11 at 4:25pm was conducted. She reported that both the refrigerator and the freezer in the nourishment kitchen should have thermometers in them. She stated that the 11pm- 7am shift were responsible for the thermometers in the refrigerator/freezer.

Unit B: Observation of the B wing refrigerator/freezer located in the nourishment kitchen on the unit was completed on 02/24/11 at approximately 5:15pm with a 3pm - 11pm B unit LPN in attendance with the surveyor. A thermometer was located hanging from a shelf in the freezer; the surveyor and the LPN were not able to read the temperature gage on that thermometer. A second thermometer was observed sitting on the floor of the freezer, the temperature reading was 10 degrees.

During the interview with the 3pm - 11 pm B unit LPN during the observation on 02/24/11 at 5:15pm, she reported that the night shift staff should be checking the refrigerator/freezer located in the nourishment kitchen. She was aware of the need for temperatures to be maintained in the refrigerator/freezers on the unit and stated that it was important to store food items at the correct temperature.

The C wing (unit) 11 pm - 7 am assignment sheet dated 02/24/11 was reviewed and included that the staff member assigned to assignment 1 also had the responsibility to clean the fridge on Wednesdays and the staff member assigned to assignment 2 had the responsibility to wipe the thermometers off on Wednesday. The assignment sheet did not include an assignment to check the temperatures in the nourishment kitchen refrigerator/freezer.

On 02/24/11 at 5:45 pm an interview with the Director of Nursing (DON), the housekeeping supervisor, the maintenance supervisor, and the administrator was completed regarding the thermometers and the temperatures in the refrigerator/freezers located in the nourishment kitchens on each unit. When asked who was responsible to check the thermometers and the temperatures in the refrigerator/freezer located in the unit nourishment kitchens, the supervisor of maintenance replied that the maintenance department completes monthly preventative maintenance rounds on each of the residential units which include checking the function of the refrigerator/freezers and the thermometers. The DON stated that the 11pm - 7am nursing staff was responsible for cleaning the refrigerator, once a week on Wednesday. Each nursing unit is responsible for their own refrigerator/freezer, and the responsibility was assigned on the unit's daily assignment sheet.

During continued interview with the DON on 02/24/11 at 6:00pm, she stated she did not know if the refrigerator/freezer thermometers were checked on a daily basis for function and temperatures, she said she could check with the unit managers.

The facility policy document titled refrigerators dated 03/19/92 included a purpose statement to keep the refrigerators at proper temperatures, free from ice buildup and door gaskets in good working order. The frequency was documented as monthly.

Following surveyor intervention, on 02/25/11 at approximately 10:00am the administrator submitted a new refrigerator and freezer policy dated 02/24/11, with an attached daily temperature log. The policy included direction for the 11pm - 7am nurse to check temperatures on the thermometers daily and record the readings. The results should be recorded on the log with the nurse 's initials. The policy included the required temperature parameters (readings) and the instruction to contact maintenance immediately if temperatures were not within the parameters stated. The administrator stated that the new policy would go into effect immediately.

10NYCRR 415.14(h)

Based on observation, and staff interviews documents the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior for three (B, C, and D) of three residential units. Specifically, the bathing areas on units B, C, and D and the shower stretchers on units C and D were not maintained in clean and sanitary condition, the wooden doors and the painted door frames on resident's rooms were not maintained without scrapes and scratches on units B, C, and D and the round wooden corridor handrails for unit B were not maintained. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The following is submitted as evidence:
Finding 1: Bathing Areas Units B, C, and D.
B Unit:

The resident bathroom in the main corridor was observed on 02/24/11 at 5:45pm, the sink, toilet seat, and toilet bowl had visible dirt and dust particles present.

A second observation of the resident bathroom in the main corridor of the B unit on 02/25/11 at 10:30am while on tour with the supervisor of maintenance and the administrator, the sink had visible dirt and dust and the toilet had not been flushed completely. The maintenance supervisor stated that the bathroom was not usually used by the residents but should be maintained and cleaned on a regular schedule. He also stated that the bathroom was obviously used today.

C Unit:
Observation of the bathing area on Unit C on 02/24/11 at 5:30pm identified the following findings;
The bathroom floor between the tub wall and the tub seat was brownish/black in color, with visible dust and dirt.
The shower stretcher had a hard brownish matter about the size of a fist under the rubber pad that was in place on top of the mesh netted stretcher base, there were also white colored circular particles present on the netting.
D Unit:
Observation of the bathing area on Unit D on 02/24/11 identified the following findings;
At 5:50pm there was visible black, dark brown matter on the floor around the tub and in the area between the tub and the chair base.

On 02/24/11 at 6pm the D unit shower stretcher was observed to have hair and dried soap on the underside of the rubber pad with a brownish rust colored stained area in the middle of the underlying netting. The plastic lining beneath the netting was filled with pooled water. The tub was observed with wet soap residue on the floor of the tub.
During an interview with a Certified Nursing Assistant (CNA) on 02/24/11 at 6:00pm, when asked about the above findings in the D unit bathing area, she stated that it was the responsibility of the CNA to clean all of the surfaces following each shower and/or tub bath.
An interview with the Registered Nurse, Infection Control Nurse on 02/24/11 at 6:15pm was completed regarding the lack of cleanliness in the shared bathing areas and the shower stretchers and tubs, she stated that the bathing equipment should be cleaned by the CNA's after each use.
Interview with the supervisor of housekeeping and the Director of Nursing (DON) on 02/24/11 at 6:15pm regarding the responsibility of cleaning the bathing areas on the units, revealed that there is a shared responsibility for the cleaning. The housekeeping staff is responsible to clean the room itself, which would include the floors, walls, and general tidying. The housekeeping supervisor stated that the housekeepers check and clean the rooms three times a day and are responsible to sign off when the task is completed. The DON stated that the CNA's should be cleaning the tub, shower chairs, and stretchers after each use.
Finding 2: Residential room doors, units B, C, and D
The supervisor of maintenance and the administrator were present during an observation tour of the residential units on 02/25/11 beginning at approximately 10:20am.
Room B6 observed at 10:24am.
The wooden resident room door was scratched, scraped, and marred. The paint on the door frame was chipped and scratched. The findings were consistent throughout the B unit.

Room B 28 observed at 10:45am, there was a vinyl piece across the entire width of the bottom of the door, it was approximately thigh high. It was not adhered to the door completely and observed to be pulling away from the door.

When the maintenance supervisor was asked about the scratches on the wooden doors and chipping of the paint on the door frames, he responded that generally the doors and the door frames required repair and maintenance. He added that the vinyl pieces were applied to cover the scratches on the wooden doors and that they also required repair and maintenance.

Rooms D 13 and D 14 observed at 10:55am had the same vinyl piece across the bottom of both doors.
Rooms D 31 and 32 were observed at 11:08am, the wooden doors were scratched and scraped near the base, the doors frames had chipped paint.
During interview at the time of the observation, the maintenance supervisor commented that the doors and door frames on D unit were in need of repair and maintenance.
The C unit wooden doors and painted door frames were observed to be scraped and scratched with chipped paint at 11:20am.
The interview with the maintenance supervisor was completed during the walking tour of the C unit, he stated that the maintenance department does not include the cosmetic maintenance of the facility during their rounds; the department focus is on the mechanical function of the facility. The facility staff should submit a work order request to communicate needed maintenance.

Finding 3: Wooden handrails, C unit
Observation on the wooden handrails on the C unit was completed on 02/25/11 at 11:30am, the rails were approximately 1 inch in diameter and were attached to the walls throughout the C unit. The rails had a pale yellowish white colored mark along the outer bottom rim throughout the unit.
During an interview with the administrator at the time of the observation, she stated that the intent is to replace the handrails using the same material that was in place on another unit. The material is sturdier, will hold up better and last longer.

10NYCRR 415.5(h)(2)

Based on observation, staff interview and record review, the facility did not ensure that clinical records were maintained in accordance with accepted professional standards and practices for 1 ( # 24) of 48 residents. Specifically, the facility did not ensure that the Treatment Administration Records (TAR), used to identify and document care for resident #24 accurately documented the use of the positioning devices as ordered for his right hand and right arm.

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

Findings are:

Resident # 24 was admitted to the facility with diagnoses including Cerebral Vascular Accident (CVA) with right hemiparesis (weakness) and aphasia (loss or reduction of language). The Minimum Data Set (MDS) (a comprehensive assessment tool) dated 11/23/10 assessed the resident as requiring assistance for activities of daily living, assistance of one to two depending on the activity.

The Interdisciplinary Care Plan, initiated on admission and updated quarterly, titled CVA with right hemiparesis included a written goal to maintain range of motion (ROM), (the normal range of movement for a joint). The written interventions included level II passive ROM right upper and right lower extremity two times a week (five times each joint), use washcloth roll in right hand at all times (remove for hygiene) and to place a small pillow under right upper extremity.

The physician orders dated 01/31/11 included the following order passive Rom Right Upper and right lower extremity 2 times per week. A wash cloth should be rolled in his right hand at all times and a small pillow should be under the RUE (right upper extremity) for positioning.

On 02/16/11 at 1:10pm the resident was observed in the main dining area during the lunch meal. He was seated in a high back recliner chair, in an upright position with his right arm positioned close to his body and his right hand resting directly on his lap. His right hand was observed to be closed in a fist position, there was no evidence of a washcloth roll in his right hand and no pillow positioned under his right upper extremity. Later that day, at 2:55pm, the resident was observed to be resting in bed with his right arm positioned close to his body and his right hand in a clenched fist position. There was no evidence of a pillow being in place below his right arm or a washcloth rolled in his right hand.

On 02/17/11 at approximately 9:30am the resident was observed in the day room, in a reclined position in the high back chair. His right arm was resting on his body and his right hand was resting directly on his lap in a closed fist position. There was no visible evidence of a pillow positioned under his right arm or a washcloth roll in his right hand.

During breakfast meal observation on 02/23/11 at 8:05am, the resident arrived in the main dining room seated in a high back recliner. His right hand was clenched with no visible signs of a splint or cushion in place in his fist. His right upper extremity was close to his body with the elbow bent and his lower arm positioned across his abdomen. There were no visible pillows or positioning devices for elevation in place.

Observation 02/24/11 at approximately 9:00 am, the resident was seated in the high back recliner chair , his right hand clenched in a fist and resting on his lap and his right arm close to his body.

During an interview at 9:10 am with the full time 7am - 3pm Certified Nursing Assistant (CNA) assigned to care for the resident on 02/24/11, she stated she uses the CNA assignment sheet as a resource for the care needs of the residents. When asked about positioning for the right arm and a washcloth roll for the right hand, she stated that she did not know if the resident should have these. She checks her assignment sheet for the care needs of the resident. The CNA assignment sheet was observed by the surveyor and the CNA, it did not include information regarding positioning of the resident's right arm or the placement of a washcloth in his right hand. The CNA stated that those things would either be done by the nurses or by nursing rehabilitation (rehab).

An observation at 2 pm on 02/24 identified resident #24 lying on his back in bed with a washcloth in place in his right hand and without a pillow under his right arm.

During an interview with the Registered Nurse, Nurse Manager (RNM) on 02/24/11 at 2:00 pm, she stated that she was the unit charge nurse that day and was responsible for treatments. She reported that, she placed a rolled washcloth in the resident's right hand earlier in the day when she was completing the treatments, because there wasn't already one in place. She did not place a pillow under his right arm. When asked how she knew what treatments needed to be done, she reported that each residents information is on their sheet and the treatment sheets are used determine what needed to be done for each resident. When asked specifically about the positioning orders for the right hand and arm of resident #24, she stated that the washcloth roll should always be in place, except for when the resident is bathed and a pillow should be in place under his right arm.

The TAR dated February 2011 was reviewed with the RNM on 02/24/11 at 2:15pm. The TAR included entries as follows; washcloth right hand at all times and small pillow under RUE positioning. Both of the treatment entries required a signature from each nursing shift. The RNM stated that a signature meant that the care had been provided for the resident. The entries for 02/24/11 were reviewed and initials (signatures) were present for both the washcloth in the right hand and the small pillow under the RUE. The RNM commented that the treatment entries should not be signed if the care was not provided, when asked specifically about the small pillow; she replied that she did not place a pillow under the RUE but, she did sign for it, which was incorrect. When observations of the resident without the washcloth in his right hand or the pillow under his RUE on 02/16, 02/17, 02/23, and 02/24 were discussed with the RNM, the treatment entries for 02/16, 02/17, 02/23, and 02/24/11 were reviewed with the RNM, all three (30) nursing shifts were signed for to indicate that the care was provided and in place. The RNM was asked to explain what a signature meant and she replied that the TAR should not be signed unless the care was provided and the TAR was incorrect.

10NYCRR 415.22(a)(1-4)

Based on interview and record review, the facility did not develop a plan of care with measurable goals and objectives to address a planned weight loss program in accordance with current standards of practice. This was evident for 1 of 48 sampled residents (# 58).

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

Findings are:

Resident # 58 was admitted on 11/9/10 with diagnoses including Acute exacerbation of Chronic Bronchitis , Congestive Heart Failure, and Coronary Artery Disease.

A review of the 14 day MDS of 11/19/10 revealed that this resident was receiving a therapeutic diet (regular, low fat, no added salt).

Interview with the consulting dietitician on on 2/25/11 at 9:45AM revealed that this therapeutic diet was a planned weight loss diet ; and that the initial dietary assessment for planned weught loss had been checked "no" in error.

A review of the interdisciplinary care plan of 11/29/10 revealed no interventions to address a planned weight loss program.

During an interview with unit Licensed Practical Nurse on 2/25/11 at 10:30AM she could give no explanation as to why the care plan did not address a planned weight loss .

415.11 (c)(1)

Based on observation, interview, and record review the facility did not ensure that a care plan was reviewed and revised as interventions to address contractures were changed. This was evident for 1 of 48 sampled residents (# 63).

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

Findings are:

Resident #63 was admitted to facility on 1/12/10 and has diagnoses including Hypertension, Status Post Cerebral Vascular Accident , and Arthritis. A review of the MDS (assessment) of 1/26/10 (Admission) revealed that this resident had no limitation, full loss of hands including fingers or wrist.

Observation of this resident on 2/23/11at 10:15AM revealed contractures of left 3,4,5,fingers with left index finger extended as well as left thumb; Right hand appears fully contracted and in tightly clenched position,

Occupational therapy evaluation of 1/13/10 revealed bilateral hand limitations rest in flexion with both upper extremities non functional

RAP notes done with the MDS indicated that the resident had bilateral hand contractures, was totally dependent in ADL, and was to have sheepskin hand rolls daily after washing hands. The resident received restorative Occupational Therapy for 3 days. Occupational Therapy was discontinued on 1/18/10 with recommendation to wear bilateral palm guards at all time. This recommendation was discontinued on 2/8/11 and MD order of this date revealed that ABD pads rolled in bilateral hands were to be used. at all times.

Interview with Occupational Therapist on 2/23/11 at 12:02PM revealed that she had involved the unit nurse in the decision to use ABD pads and notification was sent to rehab on 2/8/11. Review of treatment record for January/February 2011 revealed that the MD order of 2/8/11 for the use of ABD pads was noted on treatment record. However, the care plan was not revised to reflect the new interventions ordered on 2/8/11.

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

Based on observations, record reviews and interviews, the facility did not ensure that residents were cared for in a manner which respected their dignity during dining observations. Specifically, three residents were observed eating non- finger foods with their fingers in the Unit B dining room. This was evident for 2 residents(Residents #100 and 104).

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

Findings are:

During a lunch observation of 16 residents in the Unit B dining room on 2/16/11, at 12:00PM, Resident #100 was observed trying to manipulate her fork and spoon to grasp a piece of meat and bring it to her mouth. She did the same with her vegetables but was observed to have difficulty in getting the food to her mouth. The food either slipped off the edge of the plate or fell from between the fork and spoon. After several minutes of attempting to get the food to her mouth the resident put down the eating utensils and used her fingers to place meat and vegetables into her mouth. Resident #100 alternated between using her fingers and trying to use the utensils, without success, to consume her meal throughout the observation. Of the seven staff assisting residents in the dining room, no staff intervened to re-direct/assist the resident. Review of the resident's care plan revealed that she had not been evaluated for adaptive equipment by the Occupational Therapist (OTR), and her care plan did not address her difficulty in getting food on the fork or from the plate to her mouth.

In an interview with the Certified Nursing Assistant (CNA) at 12:50PM on 2/16/11, she was unable to explain why no staff tried to intervene to re-direct/assist the resident.

In an interview with the Licensed Practical Nurse (LPN) immediately following this observation, she said that many people have to be fed on the unit and staff do intervene when they see this behavior.

In an interview with the Head Nurse Registered Nurse (RN) at this same time, she stated that she would ask the OTR to evaluate this resident for adaptive equipment.

During a breakfast observation on Unit B on 2/23 /11 at 7:30AM, 13 residents were observed having breakfast. Six staff were assisting residents to eat. Two of the residents, (#100 and 104), were observed feeding themselves scrambled eggs using their hands. No staff intervened to re-direct/assist residents to use utensils to feed themselves.

In an interview with the Head Nurse RN immediately following this observation, she had no explanation as to why staff did not see these behaviors and intervene and she would request an OT evaluation for the second resident, as well, and care plan appropriately for both

415.5(a)

Based on interview and record review the facility did not ensure that residents drug regimen was free from unnecessary medications used without adequate monitoring. This was evident for 1 of 48 sampled residents. (# 66).

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

Findings are:

Resident # 66 has diagnoses including Hypertension.

A review of the Medication Records (MAR) of 12/18/10 to 1/14/11 revealed that this resident was receiving Coreg 6.25mg every 12 hours "hold if SBP \ < (below 90).

According to this MAR the resident did not receive the medication as ordered on 12/23/11 and the blood pressure was not monitored prior to administration of the medication on 12/24/10.

During an interview with the unit Licensed Practical Nurse on 2/24/11 at 3:01PM she stated that the only explanation she could offer was that the nurse had not documented. However, there was no documentation anywhere else in the residents' medical record.

415.12(l)(1)

Based on observation, staff interview and record review the facility did not ensure that each resident's individualized plan of care was implemented for 2 of 48 residents. Specifically, 1. For resident # 24, the facility did not ensure that positioning devices were in place as written in his Interdisciplinary Care Plan (ICP) for the right upper extremity, specifically a right hand roll was to be in place at all times in addition to a small pillow in place under his right arm; 2. For resident #29, the ICP was not implemented for release of a restraint.

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

Findings are:ne
1. Resident # 24 was admitted to the facility with diagnoses including Cerebral Vascular Accident (CVA) with right hemiparesis (weakness) and aphasia (loss or reduction of language). The Minimum Data Set (MDS) (a comprehensive assessment tool) dated 11/23/10 assessed the resident as requiring assistance for activities of daily living, assistance of one to two depending on the activity.

The Interdisciplinary Care Plan, initiated on admission and updated quarterly, titled CVA with right hemiparesis included a written goal to maintain range of motion (ROM), (the normal range of movement for a joint). The written interventions included level II passive ROM right upper and right lower extremity two times a week (five times each joint), use washcloth roll in right hand at all times (remove for hygiene) and to place a small pillow under right upper extremity.

The physician orders dated 01/31/11 included the following order passive Rom Right Upper and right lower extremity 2 times per week. A wash cloth should be rolled in his right hand at all times and a small pillow should be under the RUE (right upper extremity) for positioning.

On 02/16/11 at 1:10pm the resident was observed in the main dining area during the lunch meal. He was seated in a high back recliner chair, in an upright position with his right arm positioned close to his body and his right hand resting directly on his lap. His right hand was observed to be closed in a fist position, there was no evidence of a washcloth roll in his right hand and no pillow positioned under his right upper extremity. Later that day, at 2:55pm, the resident was observed to be resting in bed with his right arm positioned close to his body and his right hand in a clenched fist position. There was no evidence of a pillow being in place below his right arm or a washcloth rolled in his right hand.

On 02/17/11 at approximately 9:30am the resident was observed in the day room, in a reclined position in the high back chair. His right arm was resting on his body and his right hand was resting directly on his lap in a closed fist position. There was no visible evidence of a pillow positioned under his right arm or a washcloth roll in his right hand.

During breakfast meal observation on 02/23/11 at 8:05am, the resident arrived in the main dining room seated in a high back recliner. His right hand was clenched with no visible signs of a splint or cushion in place in his fist. His right upper extremity was close to his body with the elbow bent and his lower arm positioned across his abdomen. There were no visible pillows or positioning devices for elevation in place.

Observation 02/24/11 at approximately 9:00 am, the resident was seated in the high back recliner chair , his right hand clenched in a fist and resting on his lap and his right arm close to his body.

During an interview at 9:10 am with the full time 7am - 3pm Certified Nursing Assistant (CNA) assigned to care for the resident on 02/24/11, she stated that the day shift does not complete the residents morning care, he is bathed and up in the chair by 7am. She uses the CNA assignment sheet as a resource for the care needs of the residents. When asked about positioning for the right arm and a washcloth roll for the right hand, she stated that she did not know if the resident should have these. She checks her assignment sheet for the care needs of the resident. The CNA assignment sheet was observed by the surveyor and the CNA, it did not include information regarding positioning of the resident's right arm or the placement of a washcloth in his right hand. The CNA stated that those things would either be done by the nurses or by nursing rehabilitation (rehab).

The Licensed Practical Nurse (LPN) assigned to medications was interviewed on 02/24/11 at 9:20 am reported that her assignment is to administer the medications for the residents on the unit; she is not completely familiar with the residents care but could check the records. She stated that the charge nurse also completes the treatments for the residents on the unit and would better know the information regarding positioning needs for the resident's right hand and arm.

The Occupational Therapist (OTR) was interviewed on 02/24/11 at 9:30am, she stated that she had treated the resident in the past but, he had been discharged from formal therapy to Level II, which is done by nursing rehab. She had also recommended that a rolled washcloth be placed in his right hand at all times and that a small pillow be used under his right extremity. She reported that these recommendations should still be in place and followed every day. A joint observation of the resident was completed, the OT assessed the resident's right hand and arm and stated that there was not a washcloth rolled in his right hand nor was there a pillow beneath his right arm as was recommended. She assessed the resident's range of motion and found no decline in his ability.

During an interview with the Registered Nurse, Nurse Manager (RNM) on 02/24/11 at 2:00 pm, she stated that she was the unit charge nurse that day and was responsible for treatments. She reported that, she placed a rolled washcloth in the resident's right hand earlier in the day when she was completing the treatments, because there wasn't already one in place. She did not place a pillow under his right arm. When asked how she knew what treatments needed to be done, she reported that each residents information is on their sheet and the treatment sheets are used determine what needed to be done for each resident. When asked specifically about the positioning orders for the right hand and arm of resident #24, she stated that the washcloth roll should always be in place, except for when the resident is bathed and a pillow should be in placed under his right arm.

2. Resident #29 is a female resident who has resided at the facility since 2004 and has diagnoses including history of Seizures, Parkinson's Disease, Dementia, Psychoses with agitation, Anxiety Disorder, a history of falls and fractures and Osteoporosis.

A review of the most recent Minimum Data Set (an assessment tool) dated 12/12/10 revealed that the resident was to have a trunk restraint uses daily, and required total assistance with activities of daily living.

The current Interim Physician's Orders had an order dated 2/10/11 to "Start reverse click belt in gerichair at all times while OOB."

A review of the Comprehensive Care Plan (CCP) dated 3/17/10 and reviewed and revised several times, most recently 12/10/10 revealed that the resident should be placed in the gerichair during the day, with the use of a reverse click belt. Interventions included releasing the restraint every 2 hours and during meals. According to the care plan the resident's restraint was to be reviewed quarterly by the CCP team for possible reduction or removal.
A further note on the Care Plan reported that the resident had been found on the floor on 2/10/11 by the CNA "side click belt locked but had been loosened to full extent and resident slid under belt)"

The CNA who cared for the resident was interviewed at 9:40AM on 2/25/11 and when asked why the belt was in use, the CNA responded that the resident may slide down out of the chair. She further stated that the belt is released for meals and for toileting and that the resident is very smart about opening the buckle.
The CNA assignment sheet was reviewed and has instructions to "UDR 4 all meals".

The Director of Nursing (DON) was interviewed at 11:30AM and when asked why the resident had a restraint, the DON stated that the belt was to ensure the safety of the resident who may be a danger to herself. When was asked how often the restraints were released the DON stated that this was done a minimum of twice a shift.

The Licensed Practical Nurse (LPN) on the unit was interviewed and stated that the belt was released for cares, going to bathroom and activities.
A Physical Therapy Evaluation completed on 3/22/10 indicated that the resident should have a rear click belt since "she does release side belt and would most likely fall and injure herself." There was no documented evidence of further evaluations.

The Physical Therapist was interviewed on 2/24/11 at 11:45AM and he stated that less restrictive devices had been tried for this resident in the past and had been unsuccessful.

The Nursing Supervisor was interviewed at the same time and also stated that less restrictive devices had been unsuccessful with this resident.

The resident was observed in the activity room from 9:30AM until 11:45AM.
During this period the resident was seated in a reclining gerichair with a white belt which was buckled at the back of the chair. There was no attempt to release the resident's seat belt during this observation.

Based on the above interviews, there was a lack of consistency regarding the amount of time to elapse between releases of the seat belt.

415.11(c)(3)(ii)

Based on interview and record review, the facility is not conveying within 30 days of the death of a resident, the resident's funds and a final accounting of those funds, to the individual or probate jurisdiction administering the resident's estate. This occurred for 3 of 3 expired residents reviewed .

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

Findings include:

A review of facility accounts for 3 expired residents revealed the facility practice of holding resident funds beyond 30 days. For one resident, who expired on 9/12/10, the facility has continued to retain a balance of $193.13 as of 2/24/11. For another resident, who expired on 10/8/10, the facility has continued to retain a balance of 43.50 as of 2/24/11. For third resident, who expired on 11/19/10, the facility has continued to retain a balance of $129.21 as of 2/24/11.

During interview with the facility Accounts Manager on 2/24/11 at 4:00 PM, the explanation provided was that the facility cannot release the funds until an affidavit is provided by the county that the funds can be released to the resident's estate. The basis of the explanation notwithstanding, regulation requires the refund of funds to the resident estate within 30 days of the resident's expiration. This is not being implemented.

414.26(h)(5)(iv)

Based on observation and interview the facility did not ensure that the sprinkler system is continuously maintained in reliable operating condition in that the required 5-year internal inspection of the pipes has not been conducted.

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

Findings are:

On 2/16/11 at 12:30PM during record review it was noted that the sprinkler inspection reports going back as far as 2007 state " unknown " for completion of the 5-year internal inspection of the pipes.

In an interview on 2/16/11 at 1:00PM the Director of Maintenance stated that the facility was going to conduct the test when the sprinkler system was upgraded (2013). He could not offer a reason why the inspection was not conducted in 2007.

NFPA 101 (2000 edition) 19.7.6, 4.6.12, 9.7.5
NFPA 13
NFPA 25
10NYCRR 711.2(a) (1)

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

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

Findings are:

On 2/17/11 beginning at 10:25AM during a test of the fire alarm system it was observed that the strobes (visible notification appliances) located on two of four nursing units were not synchronized. These nursing units had more than three strobe lights flashing out of sequence, in any field of vision.

In an interview on 2/17/11 at 11:20AM the Director of Maintenance stated that the problem would be addressed.

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

Based on record review and interview the facility did not ensure that fire drills are held at unexpected times under varied conditions in that no scenario was documented for eleven of twenty drills reviewed and the times that the drills were conducted did not encompass the entire shift for three of three shifts reviewed.

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

Findings are:

On 2/16/11 at 12:30PM during record review it was determined that eleven of twenty drills reviewed did not describe a scenario. Additionally, six of seven drills conducted on the Day Shift occurred between 10:30AM and 11:56AM; three of six drills conducted on the Evening Shift occurred between 4:10PM and 4:23PM, and seven of seven drills conducted on the Night Shift occurred between 5:10AM and 6:02AM.

In an interview on 2/16/11 at 1:15PM the Director of Maintenance stated that the facility uses an outside contractor to conduct their fire drills.

NFPA 101 (2000 edition) 19.7.1.2
10NYCRR 711.2(a) (1)