Victory Lake Nursing Center

Based on observation and interview the facility did not ensure that a safe, functional, sanitary and comfortable environment is provided for residents, staff, and the public in that:

1. Evidence of previous water leaks and a black and grey mold-like substance and/or mildew was noted on the floor, walls, and ceiling in the Central Supply room (basement).
2. Patient care equipment and/or supplies, located in Central Supply, were coated with a mildew-like material and/or were water damaged.
3. Supplies were found being stored on the wet and/or damp floor in the Central Supply room.
4. Ceiling tiles in the Laundry Department were in poor repair.
5. Kitchen ceiling tiles are not smooth and easily cleanable and were stained with a grease-like film. Ceiling light lenses were cracked in the main kitchen and a dark mold-like residue was observed coating the interior of the lenses in the dish washing machine room.

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

Findings are (not all-inclusive):

On 6/25/10 and again on 6/28/10 between 9:10AM and 2:00PM during environmental rounds the following unsanitary conditions were observed:

1. Evidence of several previous (currently inactive) water leaks, involving three of four walls and the ceiling, were noted in the Central Supply room located in the basement. A dark mold-like material was found along moist wall and ceiling cracks. Several containers were found to be full of water from the old leaks. The insulation used to wrap a drainage pipe located in the middle of the room was dislodged and showed evidence of water damage. The exterior surface of the pipe was rusted. A similar condition was noted on a drainage pipe located in the far left area of the room.
2. A mildew-like material was found coating approximately 25 wheel chairs and other resident-use equipment (floor mats, side rail pads, mattresses, inflatable mattresses, concentrators) being stored in the far right and at the entry of the Central Supply room . (See F441)
3. Supplies located in the Central Supply room were found being stored on the floor and/or directly under old water leaks. Several of the boxes exhibited signs of water damage, including 3 boxes of exam gloves; 1 box of Chux; 5 boxes of Periclean solution; 1 box of body wash, and 2 boxes of toilet paper.
4. The laminate on four of the ceiling tiles located in the Laundry Department was separating from the insulation backing.
5. Approximately 98% of the ceiling tiles located in the kitchen were coated with a grease-like residue. Approximately 20% of the ceiling tiles had been replaced with rough-textured tiles that are not smooth and easily cleanable. Three of eight ceiling light lenses located in the production area were cracked and four of four light lenses located in the dishwashing room had a dark residue inside each lens.

In an interview on 6/25/10 at 10:30AM the Director of Maintenance stated that the leaks had been caused by cracks in the patio that is directly on top of Central Supply. He added that the facility is in the process of employing a contractor to make repairs.

In an interview on 6/25/10, the Accountant for the facility indicated that many of the issues identified that same day, namely the kitchen and laundry department ceiling tiles, have been addressed and that he is in the process of correcting the issues noted in the Central Supply room.

10NYCRR 415.29

Based on observation and staff interview, the Administrator did not provide adequate oversight or effectively utilize facility or other resources to ensure that the facility maintained an effective Infection Control Program. This is in regards to providing a safe, sanitary, and comfortable environment and to prevent the development and transmission of disease and infection. Specifically, the facility Administrator failed to ensure the basement Central Supply Room was free of unsanitary conditions.

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

Findings are:

See F441 and F493

Observations on 6/28/10 revealed the walls, ceiling and resident equipment were soiled with black grey mold-like substance in the Central Supply Room. In addition, a pervasive strong odor of mildew was present in the corridor leading to the Central Supply Room as well as inside it.

Interview with the Administrator on 6/28/10 at 4:00PM, revealed that she was aware of the unsanitary condition of the Central Supply Room. She indicated that this was the result of previous and ongoing water leaks from the patio above the Central Supply Room ceiling.

The Administrator also revealed at that time, the facility had been contacted by the Occupational Safety and Health Administration (OSHA).This was a notice of safety and or health hazards at the facility as a result of a complaint called in to the agency on 3/15/10. According to the notice, "the specific nature of the alleged hazards: 1) water is leaking throughout the ceiling into the lighting fixtures in the basement outside the classroom and beauty shop. 2) there is visible mold on the ceiling and back store room in the basement. 3) there is a leak in the pump house and exposed wing."

The Administrator stated that since that time ( 3 months) she had been contacting "contractors" for bids to fix the leaks in the patio and she planned to clean up the Central Supply Room after the patio work was completed.

The seriousness and complexity of the mold/mildew problem was not addressed by the administrator until after surveyor intervention.

415.26

Based on observation and interview, the facility did not establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. This was evidenced by the storage of resident use and nursing equipment under unsanitary conditions in the basement Central Supply Room, including:

1. A mold and/or mildew like substance was noted on the walls and ceiling, with evidence of prior leaks (i.e. water collecting in receptacles, damaged pipe insulation, water stains on walls
and cardboard boxes containing resident and nursing equipment);

2. Oxygen concentrators, tube feedings, mattresses, end tables, wheelchairs, and other nursing and resident equipment were stored in the room and exposed to potential water damage and contamination by mold and mildew, i.e. mold and mildew-like substance was noted on resident equipment, including wheelchairs, floor and bed rail pads, mattresses, etc.;

3. Clean linens were not stored in a manner necessary to prevent the spread of infection and assure the maintenance of a clean linen supply;

4. Clean and sterile nursing and resident supplies were stored together with potentially soiled housekeeping equipment in the Central Supply Room.

The storage of nursing and resident use equipment in an environment prone to moisture, with mold and/or mildew present and together with potentially soiled housekeeping equipment may contribute to the development and transmission of disease and infection.

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

Findings are:

On 6/28/10 at 12:40 PM during environmental rounds, the following was noted in the basement Central Supply Room:
The walls, ceiling and some resident use equipment were soiled with an accumulation of a black and grey mold-like substance. In addition, the floor was heavily soiled with an accumulation of dirt, dust and debris and water-damaged pipe insulation was noted. The room lacked mechanical or other ventilation, and a pervasive, strong odor of mildew was also observed in the room as well as in the corridor leading to the room. These conditions were associated with previous and ongoing water leaks from the patio above that have yet to be corrected (See citation F465).
The following unsanitary storage practices were also observed in this room:

- Nursing equipment, including oxygen concentrators and tube feedings, were stored in the room. Additionally, supplies were stored directly on the floor and/or directly under old water leaks. Several of the boxes exhibited signs of water damage, including but not limited to:
3 boxes of sterile exam gloves, 1 box of Chux pads, 5 boxes of Periclean solution, 1 box of body wash, and 2 boxes of toilet paper.
- A mildew-like substance was observed to be covering approximately 25 wheelchairs and other resident-use equipment (i.e. floor mats, side rail pads, mattresses, inflatable mattresses, etc.).
- Two of five delivery bins containing blankets and dressing gowns (storage capacity of 420 gowns and 50 blankets), were being stored uncovered in the Central Supply Room.
- Housekeeping supplies, including soiled mop buckets, mops and brooms, were stored in the Central Supply Room adjacent to the clean and sterile nursing supplies and equipment.

In an interview on 6/25/10 at 10:30 AM, the Director of Maintenance stated that the leaks in the Central Supply Room had been caused by cracks in the patio that is directly above the room.

In a subsequent interview on 6/28/10 at 12:50 PM, the Director of Maintenance and Housekeeping stated that the facility had received an extra delivery of linens from their linen supply company and had no other place to store the extra linens.

10NYCRR 415.19(c); 415.29(j)(1);(k)(4)

Based on observation and staff interview, the Governing Body did not provide oversight of the facility's operations and services to ensure its residents attain or maintain the highest practiable physical, mental, and psychological well being. Specifically, the Governing Body did not ensure that Infection Control policies were effectively implemented to prevent the potential spread of infection from the Central Supply Room where a mold-like substance was visibly present since at least March, 2010.

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

Findings are:

see F 441 and F 490

The governing body did not provide adequate oversight to effectively maintain an Infection Control Program in regards to providing a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. Specifically, the storage of resident and nursing equipment under unsanitary conditions in the
basement Central Supply Room. Mold like substance was noted on the walls, ceiling and equipment including wheelchairs. There was evidence of prior water leaks with stains on walls and cardboard boxes containing nursing and resident equipment.

In an interview with the facility Administrator on 6/28/10 at 4:00PM, she revealed that the facility had been contacted in writing by the Occupational Safety and Health Administration (OSHA) as a result of a complaint called in to the agency on 3/15/10.

In an interview on 7/1/10 at 2:05PM with the facility Director of Maintainence regarding the water leaks from the ceiling in the basement Central Supply Room, he indicated that these leaks have been happening for a "long time, probably since January, 2010." However, interview with three 3-11 shift housekeepers on 6/29/10 revealed that until surveyor intervention, these housekeepers were going into this Central Supply room each night for supplies. (at least 3 months after the OSHA complaint).

Review of the OSHA notice at that time, revealed the nature of the complaint: 1) "water is leaking throughout the ceiling into lighting fixtures in the basement outside the classroom and by the beauty shop, 2) there is visible mold on the ceiling and back stock room in the basement, 3) there is a leak in the pump house and exposed wiring."

The facility response letter dated 3/23/10 was also reviewed at that time, and revealed that a cc: was sent to the Governing Body. However, no action was taken prior to surveyor intervention.

415.26 (b)(3)(l)

Physical Plant Violation - State Only

NYCRR 710.1(c)(5) Proposals requiring a prior review limited to architectural and engineering matters.
(i)(a) Proposals where total project cost does not exceed $3,000,000, and for which a certificate of need is not otherwise required under this Part, shall be subject to review under Article 28 of the Public Health Law limited to a determination of whether the proposal is consistent with applicable statutes, codes, rules and regulations relating to the structural, architectural, engineering, environmental, safety and sanitary requirement of licensed medical facilities where the proposal relates to the acquisition, relocation, installation or modification of:

(4) heating, ventilating, air conditioning, plumbing, electrical, water supply, fixed dietary, solid waste and/or sewage disposal, and fire protection systems, other than routine maintenance and repairs or routine purchases affecting such systems.

(ii) Requests for approval of proposals described in this paragraph shall be made directly to the Bureau of Architectural and Engineering Review at the central office of the department in Albany. The applicant shall submit such information and documentation as is required to determine the acceptability of the proposal. If the Bureau of Architectural and Engineering Review determines that a proposal complies with all pertinent statutory and regulatory requirements, the director of such bureau shall notify the applicant, in writing, that the proposal is acceptable. If the Bureau of Architectural and Engineering Review determines that the proposal is not acceptable, the director of such bureau shall notify the applicant, in writing, of such determination the basis thereof. if the applicant has not submitted an acceptable proposal within 30 days of such determination, then the proposal shall be deemed an application subject to full review pursuant to section 2802 of the Public Health Law and this Part and shall be submitted to the State Hospital Review and Planning Council and the local health systems agency, with a staff recommendation of disapproval, for their recommendation.

710.7
Approval to start construction. (a) The applicant may seek approval to start construction of the project, or one or more phases thereof, upon the filing with the department completed contract documents consistent with all previous approvals.

(b) If documents are not completed, the applicant may request approval to start construction upon submission of a certification by the applicant, construction manager or contractor, and the architect that completed working drawings and specifications shall be submitted within a time period specified in the applicant's request, that such construction shall be undertaken at the applicant's risk and that approval is understood to be contingent upon submission of the completed documents as a no-cost change order.

(c) A request by the applicant pursuant to subdivision (a) or (b) of this section shall include an affidavit by the applicant's architect or engineer that the drawings:

(1) are consistent with schematic and design development drawings previously approved and, if not, the affidavit shall identify the changes and reasons for such changes; and

(2) are in compliance with the applicable provisions of this Title and all applicable local codes, statutes and regulations. In addition, the applicant shall submit an up-dated functional stack diagram consistent with section 710.2(b)(10)(i)(b) of this Part.

(d) When the submission under subdivision (a) or (b) of this section is deemed complete by the department, the applicant shall be advised in writing to commence construction pursuant to this Part.

This Requirement is not met as evidenced by:

Based on observation, interview, and record review it was determined that the facility did not seek prior review and approval from the Bureau of Architectural and Engineering Review and had not submitted a safety plan to the Regional Office for review and approval prior to starting a project in that automatic door were installed at the entrance to both the facility and Unit #100 without prior notification of and/or approval from NYSDOH.

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

Findings are:

On 6/25/10 at approximately 8:10AM during the annual recertification survey it was observed that the main entrance to the facility was in the process of being equipped with automatic door openers. Similar door openers had also been installed on Unit #100.

In an interview on 6/25/10 at 10:30AM the Administrator stated that she was not aware that the work required submission of a Limited Review application as the electrical work was being performed by a licensed electrician.

A review of construction projects on file with the regional office revealed that neither a Limited Review application nor a safety plan had been submitted prior to the start of the project observed to be in progress during the recertification survey.

NYCRR 710.1, 710.7
10NYCRR 415.29

Based on record reviews and interviews, it was determined that the facility did not ensure that care and services were provided in accordance with acceptable professional standards of practice. Specifically:1) The Physician's Order Form, Medication Administration Record (MAR) and blister package (contains unit dose of medication) for Resident # 24 had conflicting doses. 2) A recommendation by the consulting Psychiatrist to decrease Ativan for a resident with increased falls was not addressed for four months by the attending physician (Resident #10). 3)There were no parameters for pain medication as to when and what medication was to be given (Residents #8, 9 and12).

This was evident for 4 of 20 sampled residents and 1 of 4 out-of -sample residents on 3 of 3 facility units.

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

Findings include but are not limited to:

1) Resident #10 is a 64 year old male resident with diagnosis including left cerebral- vascular accident.

Review of the Psychiatric Consultations revealed that on 2/7/10, 3/3/10, 4/1/10 and 4/29/10 there were recommendations by the psychiatrist to decrease Ativan (an anti-anxiety medication) to prevent multiple falls. Further review of the medical record revealed that there was no decrease in the Ativan for these months. Review of the physician's progress notes made no reference to these recommendations. Review of the nursing notes made no reference to the psychiatrist's recommendations.

In an interview with the Director of Nursing on 6/30/10 at 10:30am she had no explanation as to why this was not done.

In an interview with the attending physician on 7/1/10 he had no explanation on why he did not address the psychiatrist's recommendations.

2. Resident #24 is a 58 year old male resident with diagnoses including end stage Chronic Obstructive Pulmonary Disease and Hypertension.

Review of the Physician's Order Form revealed Furseomide 20mg (Lasix) four tablets by mouth (60mg) 2 times a day 9am and 5pm. This document also revealed that the orders were signed by the physician, were transcribed by one nurse and reviewed as correct by two other nurses.

Review of the Medication Administration Record (MAR) revealed Furosemide 20 mg (Lasix) four tablets by mouth (60mg) 2 times a day at 9am and 5pm. A total of 23 nurses initialed this form documenting the administration of the above medication.

Observation of the pharmacy blister pack stated Furseomide 80mg (Lasix) 1 tablet 2 times a day 9am and 5pm, which is different from the dosage to be administered as indicated on the MAR and Physician's Order Form.

In an interview with the Licensed Practical Nurse (LPN) medication nurse on 6/29/10 at 10:30am, she stated she just got used to giving the medication and she knew she gave the right dose of Furseomide 80mg 1 tablet 2 times a day at 9am and 5pm.

In an interview with the Registered Nurse Manager (RN) on 6/29/10 at 10:45am, she acknowledged the discrepancy of the medication dosage between what was indicated on the Physician's Order Form, the MAR and the blister pack.

3. Resident # 9 is a 29 year old male with diagnoses including Morbid Obesity, Osteoarthritis of the knees and back.

Review of the physician order revealed that the resident had the pain medications Oxycodone 80mg every 8 hours prescribed as well as Dilaudid every 4 hours as needed (prn) for pain. Also prescribed is Motrin 200mg every 6 hours for pain prn..There were no parameters for which medication should be given for a particular level of pain.The facility had a pain scale of 0 thru 5 with no clear parameters for pain severity.

In an interview with a Licensed Practical Nurse (LPN) medication nurse on 6/28/10 at 10:30am she stated that on the pain scale, she would consider1-2 as mild pain, and 3-5 would indicate severe pain. Another LPN medication nurse interviewed on 6/28/10 at 10:35am stated she would consider 1-3 as mild pain and 4-5 as severe pain.

In an interview with the Registered Nurse (RN) Manager on 6/28/10 at 10:40am she stated that on the pain scale,1-3 would be mild pain and 4-5 would be severe pain.

This indicated that staff had differing viewpoints of the parameters for pain severity.

415.11(c)(3)(i)

Based on observation and staff interview, the facility did not promote care in a manner that maintained each resident's dignity and respect. Specifically, 1) two staff persons were observed standing, while hand- feeding 2 non-sampled residents in the unit dining room. This was evident for 1 of 3 unit dining rooms (Unit 300).

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

Finding is:

1. On 6/25/10 at 12:22PM- 12:35PM, during the lunch meal, 2 staff persons were observed standing, while hand-feeding 2 non-sampled residents in the Unit 300 dining room.

In an interview, on 7/1/10 at 1:50PM with one of the staff persons observed standing while hand-feeding a resident, she said that she was not aware that she needed to sit down when hand-feeding a resident. She further stated that she usually just assists residents with their food trays and encourages them to eat. This staff person identified herself as the facility's Human Resources Person.

415.5(a)

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Based on record review and interviews, a resident's discharge chart was incomplete. There was no evidence of the reason for the resident's discharge plan and documentation related to discharge. This was evident for 1 resident reviewed for discharge (#19).

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

Findings are:

Resident #19 is a 64 year old female with diagnoses including Pancreatic Cancer.

Review of this resident's chart revealed the following: 1) there was no Nursing discharge note. 2) Social Services note and discharge plan were unable to be located. 3) Physician discharge order was unable to be located. Physician discharge note stated "returned home" without mention of appropriate referrals.

Interview with the Director of Nursing (DON) revealed that this resident was admitted from 2/26/10 to 2/28/10 from the local hospital emergency room. This resident was transported there from home due to severe inclement weather that caused a power outage in the resident's home. This resident is a hospice patient and due to her weakened condition could not stay in her home. The hospital was unable to admit her and she was then transported to the facility for care until she could safely return home. Review of this resident's facility chart contained no indication of the reason for admission and plans for a safe discharge home.

415.3(h)(l)(v)

Based on observation, record review and staff interview, the facility did not ensure that there was adequate indication for use of anti-psychotic medications: Specifically, 1) the ongoing use of an anti-psychotic medication for a resident in the absence of attempts at gradual dose reduction (#3), This was evident for 1 of 20 sampled residents.

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

Findings are:

1) Resident #3 has diagnoses that include Senile Dementia Alzheimer type with Depression and Anxiety. The resident receives 0.5 mg of haldol twice a day for Agitation and Psychosis.

Resident #3 was observed on 7/1/10 at 10:30AM sitting in her wheel chair with her head down in a dozing position. Interview with Registered Nurse (RN) Unit Manager, at that time indicated that on occasions the resident could be found in a dozing position.

Review of Physician orders from 3/25/09- 6/25/10 (15 months), revealed that the resident has received 0.5 mg of haldol twice a day with no attempts to reduce or eliminate.

Interview with Unit Manager, RN on 7/1/10 at 1:50PM, indicated that the resident's behavior has improved since 2/10.

There have been no attempts to decrease or eliminate the 0.5mg of haldol twice a day for 15 months.

415.12[l][1]

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Based on observation and staff interviews, the facility did not ensure that residents were being hand-fed by paid feeding assistants who have successfully completed a State Approved Training course (minimum of 8 hours). This was evident for 1 non-sampled resident on 1 of 3 units (Unit 300). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

Finding is:

On 6/25/10 at 12:22PM, a person was observed standing while hand-feeding a resident in the Unit 300 dining room.

During an interview with the person observed hand-feeding the resident on 7/1/10 at 1:50PM, the person identified herself as the facility's Human Resources (HR) Person. When asked if she had completed a State Approved Training course for hand-feeding of residents, the HR Person stated no. The HR Person further stated that she only has been inserviced to assist residents with food trays or to encourage them to eat.

During an interview with the Registered Nurse (RN) Inservice Director on 7/1/10 at 3:00PM, she indicated that only resident care personnel are qualified to hand-feed residents and not office personnel.

415.13

Based on observation and interview the facility did not ensure that the building construction and type meets its original Type II partially sprinklered construction classification in that the protective fire retardant coating is missing on several structural "I" beams, located in the main supply room (basement).

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

Findings are:

On 6/25/10 at 10:10AM, during life safety rounds, it was observed that one 4 ft. and three
2 ft. sections of the fire-proofing material applied to several of the supporting "I" beams, located in Central Supply, were missing.

In an interview on 6/25/10 at 10:20AM, the Director of Maintenance stated that the facility is in the process of obtaining estimates to make repairs.

NFPA 101 (2000 edition) 19.1.6.2
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 four of seven heat detectors located in the kitchen were coated with a dark tan residue.

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

Findings are:

On 6/25/10 at 8:20AM during dietary rounds it was observed that four of seven heat detectors located in the kitchen were coated with a dark tan residue.

In an interview on 6/25/10 at 9:00AM the Director of Maintenance stated that he was not aware of the condition of the detectors but that it would be addressed.

NFPA 101 (2000 edition) 9.6.1.4
10NYCRR 415.29
NFPA 70
NFPA 72