Dental Supplier Financial Statement - PDF

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					                                                                                                                                     PRINTED: 11/20/2008
                                                                                                                                       FORM APPROVED
  New York State Department of Health
 STATEMENT OF DEFICIENCIES              (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                      (X3) DATE SURVEY
 AND PLAN OF CORRECTION                      IDENTIFICATION NUMBER:                                                                    COMPLETED
                                                                                   A. BUILDING     ______________________
                                                                                   B. WING _____________________________
                                                335497                                                                                       08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                   STREET ADDRESS, CITY, STATE, ZIP CODE

                                                                 8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR                                 ORISKANY, NY 13424

    (X4) ID               SUMMARY STATEMENT OF DEFICIENCIES                          ID                  PROVIDER'S PLAN OF CORRECTION                    (X5)
    PREFIX            (EACH DEFICIENCY MUST BE PRECEDED BY FULL                    PREFIX             (EACH CORRECTIVE ACTION SHOULD BE                COMPLETE
     TAG              REGULATORY OR LSC IDENTIFYING INFORMATION)                    TAG              CROSS-REFERENCED TO THE APPROPRIATE                 DATE
                                                                                                                  DEFICIENCY)


       I190 415.17 Dental Services                                            I190                                                                   9/19/08
      SS=D


              This Regulation is not met as evidenced by:
              415.17 Dental services. The facility shall provide
              oral hygiene care and
              routine and 24-hour emergency dental care in
              accordance with the
              comprehensive resident care plan and which
              meets generally accepted
              standards of dental and dental hygiene care and
              services.

                (a) Organization. The facility shall appoint a
              licensed and currently
              registered dentist to assist the facility in the
              development and
              implementation, in cooperation with nursing and
              medical services, of
              written dental service and oral hygiene policies
              and procedures which:

                 (1) establish oral hygiene and dental care as
              components of
              interdisciplinary resident care planning and
              treatment;

                 (2) develop an oral hygiene program to be
              jointly administered by
              nursing, dental and dental hygiene staff;

                 (3) set forth in detail how emergency care to
              alleviate pain,
              infection, or swelling and routine dental services
              are to be provided and
              the specific arrangements with dentist(s) who are
              to provide these
              services including the prompt referral of residents
              with lost or damaged
              dentures to a dentist if such residents will benefit
              from such referral;

Office of Health Systems Management / Office of Long Term Care
                                                                                                              TITLE                                 (X6) DATE

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE

STATE FORM                                                                  6899
                                                                                            MM8P11                                         If continuation sheet 1 of 5
                                                                                                                                     PRINTED: 11/20/2008
                                                                                                                                       FORM APPROVED
  New York State Department of Health
 STATEMENT OF DEFICIENCIES              (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                      (X3) DATE SURVEY
 AND PLAN OF CORRECTION                      IDENTIFICATION NUMBER:                                                                    COMPLETED
                                                                                   A. BUILDING     ______________________
                                                                                   B. WING _____________________________
                                                335497                                                                                       08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                   STREET ADDRESS, CITY, STATE, ZIP CODE

                                                                 8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR                                 ORISKANY, NY 13424

    (X4) ID               SUMMARY STATEMENT OF DEFICIENCIES                          ID                  PROVIDER'S PLAN OF CORRECTION                    (X5)
    PREFIX            (EACH DEFICIENCY MUST BE PRECEDED BY FULL                    PREFIX             (EACH CORRECTIVE ACTION SHOULD BE                COMPLETE
     TAG              REGULATORY OR LSC IDENTIFYING INFORMATION)                    TAG              CROSS-REFERENCED TO THE APPROPRIATE                 DATE
                                                                                                                  DEFICIENCY)


       I190 Continued From page 1                                             I190

              and

                 (4) establish a system of determining dental
              treatment goals for each
              resident based on the resident's need relative to
              his or her physical and
              mental level of functioning, the overall plan of
              care for the resident and
              the resident's preferences. These treatment goals
              shall range on a
              continuum, progressing from all essential dental
              services to only routine
              oral hygiene services and emergency services.
              The decision to defer
              treatment of identified dental conditions shall be
              documented based on
              physical or mental contraindications for care and
              the resident's informed
              choice.

                (b) Admission. An initial screening of each
              resident's oral health
              status shall be conducted within 48 hours of
              admission to determine the
              need for emergency care to alleviate pain,
              infection, or swelling. The
              presence and functioning of any oral prostheses
              shall be observed, and,
              with the resident's consent, the prostheses shall
              be indelibly marked for
              identification.

               (c) Oral Examination and Treatment. A
              complete oral examination of each
              resident shall be conducted by a licensed and
              currently registered dentist
              or dental hygienist within 7 days following
              completion of the initial
              comprehensive assessment in accordance with
              Section 415.11 of this Part
Office of Health Systems Management / Office of Long Term Care
STATE FORM                                                                  6899
                                                                                            MM8P11                                         If continuation sheet 2 of 5
                                                                                                                                     PRINTED: 11/20/2008
                                                                                                                                       FORM APPROVED
  New York State Department of Health
 STATEMENT OF DEFICIENCIES              (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                      (X3) DATE SURVEY
 AND PLAN OF CORRECTION                      IDENTIFICATION NUMBER:                                                                    COMPLETED
                                                                                   A. BUILDING     ______________________
                                                                                   B. WING _____________________________
                                                335497                                                                                       08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                   STREET ADDRESS, CITY, STATE, ZIP CODE

                                                                 8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR                                 ORISKANY, NY 13424

    (X4) ID               SUMMARY STATEMENT OF DEFICIENCIES                          ID                  PROVIDER'S PLAN OF CORRECTION                    (X5)
    PREFIX            (EACH DEFICIENCY MUST BE PRECEDED BY FULL                    PREFIX             (EACH CORRECTIVE ACTION SHOULD BE                COMPLETE
     TAG              REGULATORY OR LSC IDENTIFYING INFORMATION)                    TAG              CROSS-REFERENCED TO THE APPROPRIATE                 DATE
                                                                                                                  DEFICIENCY)


       I190 Continued From page 2                                             I190

              and by a dentist at least annually thereafter.
              Based on treatment
              priorities determined at each time of examination,
              an individual plan of
              continuing oral hygiene and dental care meeting
              generally accepted
              standards of dental and dental hygiene care and
              services shall be
              established, or updated, and carried out for each
              resident. If treatment
              by a dentist is needed, such treatment shall begin
              within 30 days of the
              examination. This shall include arrangements for
              transportation when the
              services of a provider outside the facility are
              required.

               (d) Records. The admission dental record and
              records of all subsequent
              dental care shall be maintained as part of the
              resident clinical record.


              Based on medical record review and staff
              interview during the standard recertification
              survey, the facility did not ensure that a complete
              oral examination of each resident shall be
              conducted by a licensed and currently registered
              dentist or dental hygienist within 7 days following
              completion of the initial comprehensive
              assessment for 1 (#23) of 10 residents.
              Specifically, the facility did not ensure one
              resident received an initial dental exam within 21
              days of admission for one resident (#23). This is
              evidenced by:

              Resident #23
              The resident did not have an initial dental exam
              within 21 days after admission.


Office of Health Systems Management / Office of Long Term Care
STATE FORM                                                                  6899
                                                                                            MM8P11                                         If continuation sheet 3 of 5
                                                                                                                                     PRINTED: 11/20/2008
                                                                                                                                       FORM APPROVED
  New York State Department of Health
 STATEMENT OF DEFICIENCIES              (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                      (X3) DATE SURVEY
 AND PLAN OF CORRECTION                      IDENTIFICATION NUMBER:                                                                    COMPLETED
                                                                                   A. BUILDING     ______________________
                                                                                   B. WING _____________________________
                                                335497                                                                                       08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                   STREET ADDRESS, CITY, STATE, ZIP CODE

                                                                 8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR                                 ORISKANY, NY 13424

    (X4) ID               SUMMARY STATEMENT OF DEFICIENCIES                          ID                  PROVIDER'S PLAN OF CORRECTION                    (X5)
    PREFIX            (EACH DEFICIENCY MUST BE PRECEDED BY FULL                    PREFIX             (EACH CORRECTIVE ACTION SHOULD BE                COMPLETE
     TAG              REGULATORY OR LSC IDENTIFYING INFORMATION)                    TAG              CROSS-REFERENCED TO THE APPROPRIATE                 DATE
                                                                                                                  DEFICIENCY)


       I190 Continued From page 3                                             I190

              The resident was admitted to the facility on 2/1/08
              with diagnoses of hypothyroidism, degenerative
              joint disease and cerebrovascular accident. The
              Minimum Data Set (MDS) dated 8/7/08 assessed
              the resident as having no short term or long term
              memory problems and moderately impaired
              decision making skills.

              Medical record review revealed that an initial
              dental examination was not completed on this
              resident until 5/5/08, 94 days after admission.

              In an interview with the Registered Unit Nurse
              Manager on 8/28/08 at 8:35 am, she stated that
              the resident had gotten skipped for a dental exam
              after admission and when this was realized, she
              was scheduled for an exam, but when it occurred,
              it was late. She was unaware of any regulation of
              when resident's need to be seen by the dentist for
              an initial exam after admission

              10 NYCRR 415.17(a)(3)(c)

       I260 415.26 Organization and Administration                            I260                                                                   9/19/08
      SS=C



              This Regulation is not met as evidenced by:
              NYCRR 415. 26 (f)(1), (2), (3)

              The nursing home shall have a written plan,
              updated at least twice a year, with procedures to
              be followed for the proper care of residents and
              personnel, and for the reception and treatment of
              mass casualty victims, in the event of an internal
              or external emergency resulting from natural or
              man-made causes including but not limited to
              earthquake, sever weather, flood, bomb threat,
              chemical spills, strike interruption of utility
              services, nuclear accidents, fire or similar
Office of Health Systems Management / Office of Long Term Care
STATE FORM                                                                  6899
                                                                                            MM8P11                                         If continuation sheet 4 of 5
                                                                                                                                     PRINTED: 11/20/2008
                                                                                                                                       FORM APPROVED
  New York State Department of Health
 STATEMENT OF DEFICIENCIES              (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                      (X3) DATE SURVEY
 AND PLAN OF CORRECTION                      IDENTIFICATION NUMBER:                                                                    COMPLETED
                                                                                   A. BUILDING     ______________________
                                                                                   B. WING _____________________________
                                                335497                                                                                       08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                   STREET ADDRESS, CITY, STATE, ZIP CODE

                                                                 8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR                                 ORISKANY, NY 13424

    (X4) ID               SUMMARY STATEMENT OF DEFICIENCIES                          ID                  PROVIDER'S PLAN OF CORRECTION                    (X5)
    PREFIX            (EACH DEFICIENCY MUST BE PRECEDED BY FULL                    PREFIX             (EACH CORRECTIVE ACTION SHOULD BE                COMPLETE
     TAG              REGULATORY OR LSC IDENTIFYING INFORMATION)                    TAG              CROSS-REFERENCED TO THE APPROPRIATE                 DATE
                                                                                                                  DEFICIENCY)


       I260 Continued From page 4                                             I260

              occurrences. The nursing home shall develop
              and implement written policies concerning
              missing residents. The nursing home shall carry
              out staff drills in accordance with the written plan
              at least twice a year.

              Based upon review of disaster drills and staff
              interview, it was determined that the facility did
              not to carry out rehearsed disaster drills for all of
              the emergencies outlined in the facility's disaster
              plan. This was evidenced as follows:

              Based upon a review of disaster drills on 8/25/08
              at 2:30 pm, it was determined that drills for the
              following events were not carried out:

              1. Chemical spills

              2. Bomb threat

              3. Missing Resident

              4. Reception and treatment of mass casualty
              victims

              5. The Director of Environmental Services
              (DES), who participates in planning disaster drills
              was interviewed at this time. The DES did not
              recall any of the above noted disaster scenarios
              being conducted as a drill. The DES has been in
              the position (of DES) for eight years.


              10 NYCRR 415.26(f)




Office of Health Systems Management / Office of Long Term Care
STATE FORM                                                                  6899
                                                                                            MM8P11                                         If continuation sheet 5 of 5
 Department of Health and Human Services                                                                                                                                      Form Approved
 Centers for Medicare & Medicaid Services                                                                                                                                     OMB NO. 0938-0390

                                                                                      Post-Certification Revisit Report
Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork
Reduction Project (0938-0390), Washington, D.C. 20503.


 (Y1)      Provider / Supplier / CLIA /                                  (Y2) Multiple Construction                                                                           (Y3) Date of Revisit
           Identification Number                                               A. Building
                                                                                                                                                                                      11/4/2008
          335497                                                                 B. Wing

 Name of Facility                                                                                                  Street Address, City, State, Zip Code

    EASTERN STAR HOME AND INFIRMAR                                                                                     8290 STATE RT 69
                                                                                                                       ORISKANY, NY 13424
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously
reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be
fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each
requirement on the survey report form).




(Y4)     Item                                (Y5)      Date            (Y4)    Item                                 (Y5)     Date            (Y4)   Item                            (Y5)         Date

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix    F0155                           10/27/2008                ID Prefix     F0226                          10/27/2008                 ID Prefix     F0285                         10/27/2008

         Reg. # 483.10(b)(4)                                  0155               Reg. # 483.13(c)                                     0226              Reg. # 483.20(m), 483.20(e)                        0285
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix    F0309                           10/27/2008                ID Prefix     F0323                          10/27/2008                 ID Prefix     F0332                         10/27/2008

         Reg. # 483.25                                        0309               Reg. # 483.25(h)                                     0323              Reg. # 483.25(m)(1)                                0332
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix    F0334                           10/27/2008                ID Prefix     F0386                          10/27/2008                 ID Prefix     F0441                         10/27/2008

         Reg. # 483.25(n)                                     0334               Reg. # 483.40(b)                                     0386              Reg. # 483.65(a)                                   0441
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC




 Reviewed By                         Reviewed By                         Date:                     Signature of Surveyor:                                                             Date:

 State Agency

 Reviewed By                         Reviewed By                         Date:                     Signature of Surveyor:                                                             Date:
 CMS RO

  Followup to Survey Completed on:                                                                      Check for any Uncorrected Deficiencies. Was a Summary of
                                                                                                          Uncorrected Deficiencies (CMS-2567) Sent to the Facility?
                            8/28/2008                                                                                                                                                   YES        NO

 Form CMS - 2567B (9-92)                                                                           Page 1 of 1                                                      Event ID:       MM8P12
                                                                                                                                                                              AH Form Approved
                                                                                                                                                                                    11/20/2008



                                                                                 State Form: Revisit Report

 (Y1)      Provider / Supplier / CLIA /                              (Y2) Multiple Construction                                                                   (Y3) Date of Revisit
           Identification Number                                           A. Building
                                                                                                                                                                         11/4/2008
          2                                                                 B. Wing

 Name of Facility                                                                                          Street Address, City, State, Zip Code

   EASTERN STAR HOME AND INFIRMAR                                                                             8290 STATE RT 69
                                                                                                              ORISKANY, NY 13424
This report is completed by a State surveyor to show those deficiencies previously reported that have been corrected and the date such corrective action was accomplished. Each
deficiency should be fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the State Survey Report (prefix
codes shown to the left of each requirement on the survey report form).




(Y4)     Item                             (Y5)       Date          (Y4)   Item                              (Y5)     Date         (Y4)   Item                          (Y5)        Date

                                                 Correction                                                        Correction                                                       Correction
                                                 Completed                                                         Completed                                                        Completed
       ID Prefix   I190                          10/27/2008               ID Prefix   I260                         10/27/2008              ID Prefix

         Reg. # 415.17                                      190             Reg. # 415.26                                   260              Reg. #                                          ZZZZ
           LSC                                                                LSC                                                               LSC

                                                 Correction                                                        Correction                                                       Correction
                                                 Completed                                                         Completed                                                        Completed
       ID Prefix                                                          ID Prefix                                                        ID Prefix

         Reg. #                                             ZZZZ            Reg. #                                          ZZZZ             Reg. #                                          ZZZZ
           LSC                                                                LSC                                                               LSC

                                                 Correction                                                        Correction                                                       Correction
                                                 Completed                                                         Completed                                                        Completed
       ID Prefix                                                          ID Prefix                                                        ID Prefix

         Reg. #                                             ZZZZ            Reg. #                                          ZZZZ             Reg. #                                          ZZZZ
           LSC                                                                LSC                                                               LSC

                                                 Correction                                                        Correction                                                       Correction
                                                 Completed                                                         Completed                                                        Completed
       ID Prefix                                                          ID Prefix                                                        ID Prefix

         Reg. #                                             ZZZZ            Reg. #                                          ZZZZ             Reg. #                                          ZZZZ
           LSC                                                                LSC                                                               LSC

                                                 Correction                                                        Correction                                                       Correction
                                                 Completed                                                         Completed                                                        Completed
       ID Prefix                                                          ID Prefix                                                        ID Prefix

         Reg. #                                             ZZZZ            Reg. #                                          ZZZZ             Reg. #                                          ZZZZ
           LSC                                                                LSC                                                               LSC




 Reviewed By                     Reviewed By                        Date:                    Signature of Surveyor:                                                      Date:

 State Agency

 Reviewed By                     Reviewed By                        Date:                    Signature of Surveyor:                                                      Date:
 CMS RO

 Followup to Survey Completed on:                                                                Check for any Uncorrected Deficiencies. Was a Summary of
                                                                                                   Uncorrected Deficiencies (CMS-2567) Sent to the Facility?
                          8/28/2008                                                                                                                                       YES        NO
 STATE FORM: REVISIT REPORT                 (5/99)                                           Page 1 of 1                                                Event ID:      MM8P12
                                                                                                                                                           PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                                    FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                                OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                  (X1) PROVIDER/SUPPLIER/CLIA                    (X2) MULTIPLE CONSTRUCTION                                  (X3) DATE SURVEY
 AND PLAN OF CORRECTION                          IDENTIFICATION NUMBER:                                                                                    COMPLETED
                                                                                           A. BUILDING          01

                                                                                           B. WING _____________________________
                                                              335497                                                                                              08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                                     STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                     8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                     ORISKANY, NY 13424

    (X4) ID                 SUMMARY STATEMENT OF DEFICIENCIES                                ID                      PROVIDER'S PLAN OF CORRECTION                          (X5)
    PREFIX              (EACH DEFICIENCY MUST BE PRECEDED BY FULL                          PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE                     COMPLETION
                        REGULATORY OR LSC IDENTIFYING INFORMATION)                                               CROSS-REFERENCED TO THE APPROPRIATE                       DATE
     TAG                                                                                    TAG
                                                                                                                              DEFICIENCY)


      K 050 NFPA 101 LIFE SAFETY CODE STANDARD                                                 K 050                                                                  9/19/08
      SS=C
                Fire drills are held at unexpected times under
                varying conditions, at least quarterly on each shift.
                The staff is familiar with procedures and is aware
                that drills are part of established routine.
                Responsibility for planning and conducting drills is
                assigned only to competent persons who are
                qualified to exercise leadership. Where drills are
                conducted between 9 PM and 6 AM a coded
                announcement may be used instead of audible
                alarms. 19.7.1.2




                This STANDARD is not met as evidenced by:
                Based upon interview and review of records, it
                was determined that fire drills were not held at
                varying times for all of the drills conducted on two
                of the three work shifts in the facility for the prior
                year. This resulted in the potential for less than
                minimal harm and is evidenced as follows:

                1. The Facility Survey Report which indicates
                dates and times of drills for the previous 12
                months, was reviewed on 8/26/08 at 2:00 pm. All
                of the drills conducted during the evening and
                night shifts, occurred within a half hour time
                frame. This is noted as follows:

                Evening shift

                8/31/07 Fire Drill on 3:00 pm to 11:00 pm shift
                conducted at 3:35 pm

                11/28//07 Fire Drill on 3:00 pm to 11:00 pm shift
                conducted at 3:55 pm

                2/29/07 Fire Drill on 3:00 pm to 11:00 pm shift
                conducted at 3:37 pm

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE                                                     TITLE                                       (X6) DATE




Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.


FORM CMS-2567(02-99) Previous Versions Obsolete                        Event ID: MM8P21             Facility ID: 0624                               If continuation sheet Page 1 of 4
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING          01

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      K 050 Continued From page 1                                                        K 050

               5/30/08 Fire Drill on 3:00 pm to 11:00 pm shift
               conducted at 4:05 pm

               Night shift

               10/30/07 Fire Drill on 11:00 pm to 7:00 am shift
               conducted at 5:00 am

               1/30/08 Fire Drill on 11:00 pm to 7:00 am shift
               conducted at 4:43 am

               4/28/08 Fire Drill on 11:00 pm to 7:00 am shift
               conducted at 4:30 am

               7/31/08 Fire Drill on 11:00 pm to 7:00 am shift
               conducted at 5:00 am

               2. The Director of Environmental Services was
               interviewed at 3:00 pm on 8/25/08, who verified
               the drills that were noted above.

            2000 LSC 19.7.1.2
            10 NYCRR 415.29 (a)(2), 711.2 (a)(1)
            1997 LSC 13-7.1.2
      K 061 NFPA 101 LIFE SAFETY CODE STANDARD                                           K 061                                                          9/19/08
       SS=F
               Required automatic sprinkler systems have
               valves supervised so that at least a local alarm
               will sound when the valves are closed. NFPA
               72, 9.7.2.1




               This STANDARD is not met as evidenced by:
               Based upon observation and interview, it was
               determined that the facility did not provide alarm

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P21            Facility ID: 0624                       If continuation sheet Page 2 of 4
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING          01

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      K 061 Continued From page 2                                                        K 061
               supervision to the main sprinkler shut off valves
               located in the maintenance shop. Section 9.7.2.1
               of the NFPA Life Safety Code (2000 ed.) required
               a supervisory signal be provided to indicate a
               condition that would impair the satisfactory
               operation of the sprinkler system. Monitoring
               shall include, but shall not be limited to,
               monitoring of control valves, fire pump power
               supplies and running conditions, water tank levels
               and temperatures, tank pressure and air pressure
               on dry-pipe valves. Supervisory signals shall
               sound and shall be displayed either at a location
               within the protected building that is constantly
               attended by qualified personnel or at an
               approved, remotely located receiving facility. This
               results in the potential for more than minimal
               harm that is not immediate jeopardy and is
               evidenced as follows:

               The two fire service valves were observed in the
               maintenance shop on 8/27/08 at 10:15 am. A
               sign on the valves read "Main water shut off for
               the following: sprinkler shut off, hydrant shut off;
               only shut off with fire department present".
               Although the valves were chained and padlocked
               in the open position, these two valves were not
               equipped with alarm supervision. The Director of
               Environmental Services was interviewed at this
               time who indicates that closing the valve/s would
               shut the water for the hydrants and the sprinklers
               for the entire building, without any alarm, trouble
               signal, etc.


               2000 LSC 9.7.2.1, 9.7.5
               1998 NFPA 25 Chapters 2 & 3
               1999 NFPA 72 2-9

               10 NYCRR 415.29(a)(2), 711.2(a)(1), 711.2(a)(8),

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P21            Facility ID: 0624                       If continuation sheet Page 3 of 4
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING          01

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      K 061 Continued From page 3                                                        K 061
               711.2(a)(20)
               1997 LSC 7-7.2.1, 7-7.5
               1996 NFPA 13 Standard for the Installation of
               Sprinkler Systems
               1996 NFPA 72 National Fire Alarm Code




FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P21            Facility ID: 0624                       If continuation sheet Page 4 of 4
                                                                                                                                                           PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                                    FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                                OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                  (X1) PROVIDER/SUPPLIER/CLIA                    (X2) MULTIPLE CONSTRUCTION                                  (X3) DATE SURVEY
 AND PLAN OF CORRECTION                          IDENTIFICATION NUMBER:                                                                                    COMPLETED
                                                                                           A. BUILDING         ______________________

                                                                                           B. WING _____________________________
                                                              335497                                                                                              08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                                     STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                     8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                     ORISKANY, NY 13424

    (X4) ID                 SUMMARY STATEMENT OF DEFICIENCIES                                ID                      PROVIDER'S PLAN OF CORRECTION                          (X5)
    PREFIX              (EACH DEFICIENCY MUST BE PRECEDED BY FULL                          PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE                     COMPLETION
                        REGULATORY OR LSC IDENTIFYING INFORMATION)                                               CROSS-REFERENCED TO THE APPROPRIATE                       DATE
     TAG                                                                                    TAG
                                                                                                                              DEFICIENCY)


      F 155 483.10(b)(4) NOTICE OF RIGHTS AND                                                  F 155                                                                  9/19/08
      SS=D SERVICES

                The resident has the right to refuse treatment, to
                refuse to participate in experimental research,
                and to formulate an advance directive as
                specified in paragraph (8) of this section.




                This REQUIREMENT is not met as evidenced
                by:
                Based of medical record review and staff
                interviews during the standard recertification
                survey the facility did not ensure for one
                (Resident #36) of seven residents reviewed that
                the resident's advanced directives were identified.
                Specifically, the resident was admitted with
                advance directives documenting a do not
                resuscitate (DNR) order and the facility identified
                the resident as having a full code staus
                (resuscitation).

                Resident #36
                The resident was admitted to the facility on
                6/12/08 with diagnoses of Alzheimer's disease,
                depression and anemia. The Minimum Data Set
                (MDS) dated 6/12/08 assessed the resident to
                have moderately impaired cognition with memory
                problems.

                The resident had a DNR order dated 1/24/07
                identifyng the resident's advanced directives.
                The facility's advanced directives form dated
                6/12/08, identified the resident as having full code
                status.

                Interdisciplinary Progress Notes written by the
                Director of Social Services, dated 6/12/08
                (untimed) documented that the resident's

LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE                                                     TITLE                                       (X6) DATE




Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that
other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days
following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14
days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued
program participation.


FORM CMS-2567(02-99) Previous Versions Obsolete                        Event ID: MM8P11             Facility ID: 0624                              If continuation sheet Page 1 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 155 Continued From page 1                                                        F 155
               advanced directives are to be a DNR, all
               paperwork work is completed and a DNR order
               was written.

               The resident's Comprehensive Care Plan (CCP)
               dated 6/25/08 documented that the resident had
               advanced directives for a full code, which is
               contrary to the resident's wishes.

               Physician orders dated 7/12/08 identifed the
               resident's advance directives to include a full
               code (resuscitation), which is contrary to the
               resident's wishes.

               Interview with the Registered Nurse Manager
               (RNM) on 8/27/08 at 11:00 am, who responded to
               questioning regarding the resident's DNR order,
               stated that the order means that the resident
               doesn't want to be a DNR.


            10 NYCRR 415.3(e)(1)(ii)
      F 226 483.13(c) STAFF TREATMENT OF RESIDENTS                                       F 226                                                          9/19/08
      SS=E
               The facility must develop and implement written
               policies and procedures that prohibit
               mistreatment, neglect, and abuse of residents
               and misappropriation of resident property.


               This REQUIREMENT is not met as evidenced
               by:
               Based upon staff interviews and review of
               employee records, the facility did not ensure the
               implementation of the policy and procedure for
               training employees regarding abuse. Specifically,
               the facility did not provide abuse training on an
               annual basis for four (4) of four (4) staff personnel
               during the standard recertification survey. This

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 2 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 226 Continued From page 2                                                        F 226
               resulted in the potential for less than minimal
               harm that is not immediate jeopardy. This was
               evidenced by:

               A review of four (4) employees training records
               revealed that the four (4) employees did not
               receive annual abuse training during a period of
               time from January 2007 to the present date of
               August 28, 2008.

               A review of the facility's Abuse Policy and
               Procedure for employees, which was revised on
               5/2000 revealed documentation that all new
               employees will be inserviced on resident abuse
               and existing employees will be inserviced
               annually and as needed.

               During an interview on 8/28/08 at 9:45 am, the
               Staff Development Co-ordinator (SDC), confirmed
               that the four employees selected for the above
               review did not receive abuse training from 1/1/07
               to 8/28/08. In addition, the SDC stated that her
               position as SDC was only part time until July of
               2007 at which time she assumed the full time
               position as SDC.

            10 NYCRR 415.4(b)
      F 285 483.20(m), 483.20(e) PREADMISSION                                            F 285                                                          9/19/08
      SS=D SCREENING

               A facility must coordinate assessments with the
               pre-admission screening and resident review
               program under Medicaid in part 483, subpart C to
               the maximum extent practicable to avoid
               duplicative testing and effort.

               A nursing facility must not admit, on or after
               January 1, 1989, any new residents with:
                (i) Mental illness as defined in paragraph (m)(2)

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 3 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 285 Continued From page 3                                                        F 285
               (i) of this section, unless the State mental health
               authority has determined, based on an
               independent physical and mental evaluation
               performed by a person or entity other than the
               State mental health authority, prior to admission;
                   (A) That, because of the physical and mental
               condition of the individual, the individual requires
               the level of services provided by a nursing facility;
               and
                   (B) If the individual requires such level of
               services, whether the individual requires
               specialized services for mental retardation.
                 (ii) Mental retardation, as defined in paragraph
               (m)(2)(ii) of this section, unless the State mental
               retardation or developmental disability authority
               has determined prior to admission--
                   (A) That, because of the physical and mental
               condition of the individual, the individual requires
               the level of services provided by a nursing facility;
               and
                   (B) If the individual requires such level of
               services, whether the individual requires
               specialized services for mental retardation.

               For purposes of this section:
                  (i) An individual is considered to have "mental
               illness" if the individual has a serious mental
               illness defined at §483.102(b)(1).
                  (ii) An individual is considered to be "mentally
               retarded" if the individual is mentally retarded as
               defined in §483.102(b)(3) or is a person with a
               related condition as described in 42 CFR 1009.


               This REQUIREMENT is not met as evidenced
               by:
               Based on medical review and staff interview,
               during the annual survey it was determined that
               the facility did not ensure that the required

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 4 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 285 Continued From page 4                                                        F 285
               pre-admission screening and resident review
               (PASRR) was completed prior to admission.
               Specifically, the facility admitted the resident with
               a diagnosis of mental retardation and did not
               complete the required PASRR.

               Resident #76
               The resident was admitted to the facility on 5/1/02
               with diagnoses of mental retardation,
               hypertension and obesity. The Minimum Data
               Set (MDS) dated 8/7/08 assessed the resident to
               have moderately impaired cognition with memory
               problems.

               The Patient Review Instrument (PRI) dated
               4/24/02 identified the resident as requiring a Level
               two screen, to determine if additional services
               were needed. A PRI dated on 7/2/07 was
               incomplete and did not include the required Level
               two screen.

               During an interview on 8/27/08 at 11:35 am ,
               Director of Social Services stated she was trying
               to secure a Level two screen.


            10 NYCRR 415.11(e)
      F 309 483.25 QUALITY OF CARE                                                       F 309                                                          9/19/08
      SS=G
               Each resident must receive and the facility must
               provide the necessary care and services to attain
               or maintain the highest practicable physical,
               mental, and psychosocial well-being, in
               accordance with the comprehensive assessment
               and plan of care.




               This REQUIREMENT is not met as evidenced

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 5 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 309 Continued From page 5                                                        F 309
               by:
               Based on medical record review and staff
               interviews during the annual survey it was
               determined that the facility did not ensure two
               residents (#57 and #66) of seven residents
               received consistent care for diabetic
               management. Specifically, the facility did not
               ensure that residents with hypoglycemia (low
               blood sugar) were assessed, did not consistently
               notify the physician of hypoglycemic events, did
               not ensure that residents with hypoglycemia
               received medications as ordered by the physician,
               and did not assess diabetic residents blood
               sugars when the resident experienced a change
               in condition. This resulted in actual harm for
               resident (# 66) that is not immediate jeopardy.
               This is evidenced by the following:

               Resident #66
               The resident was admitted to the facility with
               diagnoses of diabetes, hypertension and
               dementia. The Minimum Data Set (MDS)
               assessment dated 4/26/08 assessed the resident
               to have moderately impaired cognition with
               memory problems.

               Physician orders dated 1/24/08 document that the
               resident is to have
               Glucagen 1milligram (mg). for a Chem Strip
               (CS/glucose level) of 60 or less, and to recheck in
               thirty minutes. If the CS is 90 or below, call the
               physician.

               The Comprehensive Care Plan (CCP), last
               revised 4/26/08, titled diabetes management
               includes approaches to monitor for signs and
               symptoms of hypoglycemia including flushed skin,
               lethargy, thirst and confusion.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 6 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 309 Continued From page 6                                                        F 309
               Licensed Practical Nurse (LPN) nurse's notes
               dated 2/4/08 at 10:00 pm document that the
               resident was noted to be very lethargic, was
               flushed with cool skin to touch and complained of
               not feeling well. The note continues that the
               resident slept through supper and did not eat
               solids or drink liquids. There is no documentation
               that the resident's CS was checked, that a
               Registered Nurse (RN) completed an
               assessment, or that the physician was notified.

               LPN nurse's note dated 2/5/08 at 4:30 am
               documents that the resident was lethargic. There
               was no documentation that a CS was checked or
               that the RN did an assessment. An additional
               note at 9:30 pm documents that the resident is
               very lethargic with a flushed face, diaphoretic
               (sweat) and was drooling. The CS was noted to
               be 21 and 1 mg of Glucagen was administered.
               The CS was re-checked in ten minutes and noted
               to be 23 and the Glucagen was repeated, with a
               repeat CS to be 46. There is no documentation
               that a RN completed an assessment.

               LPN nurse's notes on 2/6/08 at 3:15 am
               document that the resident was unresponsive
               with fixed and dilated pupils, diaphoretic, pale,
               clammy with limp upper and lower extremities,
               was drooling and gurgling. Additionally noted at
               3:45 am, was that the CS was 74. At 7:30 am the
               resident's CS was 31; at 11:30 am the CS was 29
               and Glucagen was given. The repeat CS was 85,
               the physician was notified and the resident was
               transported to the hospital. The resident received
               three boluses of dextrose 50% and was
               re-admitted to the facility at 5:45 pm.

               LPN nurse's notes date 2/7/08 at 12:30 am
               document that the resident complained of being

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 7 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 309 Continued From page 7                                                        F 309
               uncomfortable and not able to sleep. The CS
               was noted to be 48, and the resident received
               eight ounces of orange juice and one-quarter of a
               sandwich, which is contrary to the physician's
               orders. A re-check CS was documented as 60
               and the resident received three and one-half
               ounces of "another pudding", which is contrary to
               the physician's orders.

               Interview with the Medical Director on 8/28/08 at
               3:00 pm who responded to questioning that the
               physician's orders were not being followed, that
               his concern was that there were questions
               regarding his management of the residents.

               Interview with the DON on 8/28/08 at 3:45 pm
               who responded to questioning regarding 2/6/08
               why the CS was done thirty minutes after noting a
               change in the resident's condition, that it was
               probably done at 3:15 am, but documented at
               3:45 am.

               Resident #57
               The resident was admitted to the facility on
               5/01/01 with diagnoses of stroke with aphasia,
               diabetes and dementia. The Minimum Data Set
               (MDS) dated 8/15/08 assessed the resident to
               have moderately impaired cognition with memory
               problems, inability to understand others or to be
               understood and requires parenteral feeding
               (through a tube).

               Physician orders dated 6/26/08 (untimed)
               documented an order for Glucagen (concentrated
               sugar) 1 milligram (mg.) as needed for a blood
               sugar of less than 60 (normal 70-100), repeat the
               blood sugar in thirty minutes and notify the
               physician if less than ninety. Additionally, an
               order was written for chemstrips (CS) (blood

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 8 of 27
                                                                                                                                             PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                      FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 309 Continued From page 8                                                        F 309
               sugar level) every twelve hours with sliding insulin
               coverage. The facility did not ensure that resident
               #57 with hypoglycemia received medications as
               ordered by the physician

               The Comprehensive Care Plan (CCP) titled
               diabetes mellitus initiated 11/28/07 and last
               revised 8/20/08 includes approaches including
               monitor for signs and symptoms of
               hypo/hyperglycemia, CS every twelve hours, keep
               physician informed of blood sugars, Glucagen
               1mg. for a CS under 60, repeat CS in thirty
               minutes and if under 90, notify physician.

               Nurse's notes on 11/20/07 at 11:30 am
               documented that the resident's blood sugar was
               reported by the laboratory to be 50 (normal
               70-100). There is no documentation that the
               resident received Glucagen, which is contrary to
               the physician's orders. Nurse's notes on 5/25/08
               at 12:00 pm document that the resident's CS
               (blood sugar level) was 54 and the resident was
               given 150cc of orange juice, which is contrary to
               the physician's orders. A repeat CS was 72,
               without documentation of an intervention or
               notification of the physician, which is contrary to
               the physician's orders.

               Interview with the Director of Nursing (DON) on
               8/26/08 at 2:45 pm who stated that the facility
               does not have a diabetes mellitus protocol but
               has specific physician orders in place for each
               resident's diabetic management.

               Interview on 8/27/08 at 2:20 pm with the Licensed
               Practical Nurse who documented the nurse's note
               on 5/25/08, who replied to questioning of giving
               the resident orange juice, that providing orange
               juice was the physician's standing order to be

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                      If continuation sheet Page 9 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 309 Continued From page 9                                                        F 309
               given to the resident first before Glucagen,
               because the Glucagen raises the blood sugar too
               high.




            10 NYCRR 415.12
      F 323 483.25(h) ACCIDENTS AND SUPERVISION                                          F 323                                                           9/19/08
      SS=E
               The facility must ensure that the resident
               environment remains as free of accident hazards
               as is possible; and each resident receives
               adequate supervision and assistance devices to
               prevent accidents.




               This REQUIREMENT is not met as evidenced
               by:
               Based upon observation and interview, it was
               determined that the facility did not safeguard
               areas and/or equipment to minimize the potential
               of accident hazards to wandering residents.
               Nourishment rooms on three of three units
               contained heated glass coffee pots ranging in
               temperatures from 140 to 147 degrees F., were
               accessible to residents. Treatment carts on two of
               three units (Carey and Jordan) were unlocked
               and unsupervised, and the medication room
               (Jordon unit) was found unlocked. This results in
               the potential for more than minimal harm that is
               not immediate jeopardy and is evidenced as
               follows:

               1. The nourishment room across from room 39
               (Carey unit) contained a glass coffee pot that was
               on at this time of 10:40 am on 8/25/08. The pot
               was hot to the touch and the temperature of the

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 10 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 323 Continued From page 10                                                       F 323
               outside of the pot was noted at 147 degrees F.
               The door to this room was unlocked. This
               observation was again noted on 8/28/08 at 11:10
               am when the temperature of the coffee pot was
               148 degrees F.

               2. The nourishment room on the MacDonald unit
               contained a hot coffee pot on the counter when
               observed on 8/25/08 at 11:00 am. The door was
               not locked and the temperature of the outside of
               the pot measured 142 degrees F.

               3. The kitchenette on the Jordan unit was noted
               to contain a glass coffee pot on the counter that
               was on at this time of 11:10 am on 8/25/08. The
               door to this room was open wide and the
               temperature of the pot was 140 degrees F.

               4. On 8/26/08 at 4:20 pm, the medication room
               on the Jordan unit was noted unlocked. Bottles of
               stock medicines were on the counter. Interview
               with the Registered Nurse at 4:45 pm on this
               date, confirmed that the door was unlocked.

               5. On 8/26/08 at 10:00 am, the treatment cart on
               the Carey unit was unlocked and unsupervised,
               with the keys in the lock.

               6. On 8/26/08 at 10:50 am, the treatment cart on
               the Jordan unit was unlocked.

               7. Interview with the Director of Environmental
               Services on 8/28/08 at 10:30 am acknowledged
               the presence of the hot coffee pots in accessible
               locations to residents.

            10NYCRR 415.12(h)(1)
      F 332 483.25(m)(1) MEDICATION ERRORS                                               F 332                                                           9/19/08
      SS=E

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 11 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 332 Continued From page 11                                                       F 332
               The facility must ensure that it is free of
               medication error rates of five percent or greater.




               This REQUIREMENT is not met as evidenced
               by:
               Based on observations, medical record review
               and staff interviews, the facility did not ensure that
               it was free of medication error rates of 5 percent
               (%) or greater during the standard re-certification
               survey. Specifically, during the observation of the
               medication pass of forty (40) medication
               opportunities on three (3) units by six (6) nurses
               on two (2) shifts there were two (2) errors noted
               resulting in an error rate of 5 %. This resulted in
               no actual harm with the potential for more than
               minimal harm that is not immediate jeopardy. This
               is evidenced by:

               Resident #11
               The facility did not ensure that Zoloft 100
               milligrams (mg),an anti-depressant, was
               administered as ordered by the physician.

               The resident was admitted to the facility on 4/8/08
               with the diagnoses of Alzheimer's disease,
               depression, and hypertension. The Minimum data
               Set (MDS) dated 7/10/08 assessed the resident
               as having short term memory impairment, intact
               long term memory and moderately impaired
               cognitive decision making skills.

               An observation of medication pass on 8/26/08 at
               10:15 am, revealed that resident received Zoloft
               50 mg, one and a half (1 1/2) tablets; (75 mg )
               instead of Zoloft 100 mg as ordered by the
               physician.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 12 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 332 Continued From page 12                                                       F 332
               A physician order dated 8/5/08 revealed an order
               for Zoloft 100 mg tablet one (1) by mouth every
               day.

               The medication administration record (MAR) for
               August, 2008 revealed documentation for Zoloft
               100 mg tablet one (1) by mouth every day.

               The licensed practical nurse (LPN) had charted
               on the MAR that he had administered Zoloft 100
               mg to this resident when he had actually
               administered 75 (mg ) of Zoloft for the 10:00 am
               dose on 8/26/08.

               During an interview on 8/26/08 at 10:25 am, the
               LPN medication nurse did not mention that he
               had administered the incorrect dose of Zoloft .
               When questioned if there was another blistex
               container for a different dose of Zoloft, the LPN
               responded "no". At the time of the medication
               pour and pass, the LPN had not checked the
               medication room to determine if there was a
               blistex container for Zoloft 100 mg. During a
               interview on 8/26/08 at 2:45 pm, the LPN stated
               he realized he had made a medication error and
               he had notified the charge nurse.

               During an interview on 8/26/08 at 2:45 p.m., the
               charge nurse stated that the above noted incident
               was a medication error. In addition, she stated
               that the resident's correct dose of Zoloft 100 mg
               was available in the medication room on the unit
               at the time of the medication pass that am.




               Resident #74
               The facility did not ensure that glipizide, a
               medication used to lower blood sugar levels, was

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 13 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 332 Continued From page 13                                                       F 332
               administered after supper, as ordered by the
               physician.

               The resident was admitted to the facility on
               1/10/07 with the diagnoses of diabetes mellitus,
               hypothyroidism and depression. The MDS dated
               7/10/08 assessed the resident as having short
               term memory impairment, intact long term
               memory and moderately impaired cognitive
               decision making skills .

               During observation of a medication pass on
               8/26/08 at 4:50 pm, the Registered Nurse (RN)
               administered glipizide 5 mg by mouth, before the
               resident ate supper.

               A physician's order dated 7/10/08 revealed an
               order for glipizide 5 mg by mouth after supper and
               to hold the Zoloft if the resident does not eat
               supper.

               During an interview on 8/26/08 at 4:55 pm, the
               RN stated that she gave the resident the
               medication before supper because she knew that
               the resident usually eats her supper.

               During an interview on 8/26/08 at 5:05 pm, the
               Staff Educator /RN stated that the RN had made
               a medication error because the Zoloft was
               administered before supper when both the
               physician's order and MAR revealed
               documentation to give the Zoloft after supper and
               to hold the Zoloft if the resident does not eat
               supper.




               10 NYCRR 415.12 (m)(1)

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 14 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 483.25(n) INFLUENZA AND PNEUMOCOCCAL                                         F 334                                                           9/19/08
      SS=E IMMUNIZATION

               The facility must develop policies and procedures
               that ensure that --
               (i) Before offering the influenza immunization,
               each resident, or the resident's legal
               representative receives education regarding the
               benefits and potential side effects of the
               immunization;
               (ii) Each resident is offered an influenza
               immunization October 1 through March 31
               annually, unless the immunization is medically
               contraindicated or the resident has already been
               immunized during this time period;
               (iii) The resident or the resident's legal
               representative has the opportunity to refuse
               immunization; and
               (iv) The resident's medical record includes
               documentation that indicates, at a minimum, the
               following:
                 (A) That the resident or resident's legal
               representative was provided education regarding
               the benefits and potential side effects of influenza
               immunization; and
                 (B) That the resident either received the
               influenza immunization or did not receive the
               influenza immunization due to medical
               contraindications or refusal.

               The facility must develop policies and procedures
               that ensure that --
               (i) Before offering the pneumococcal
               immunization, each resident, or the resident's
               legal representative receives education regarding
               the benefits and potential side effects of the
               immunization;
               (ii) Each resident is offered a pneumococcal
               immunization, unless the immunization is
               medically contraindicated or the resident has

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 15 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 Continued From page 15                                                       F 334
               already been immunized;
               (iii) The resident or the resident's legal
               representative has the opportunity to refuse
               immunization; and
               (iv) The resident's medical record includes
               documentation that indicated, at a minimum, the
               following:
                 (A) That the resident or resident's legal
               representative was provided education regarding
               the benefits and potential side effects of
               pneumococcal immunization; and
                 (B) That the resident either received the
               pneumococcal immunization or did not receive
               the pneumococcal immunization due to medical
               contraindication or refusal.
               (v) As an alternative, based on an assessment
               and practitioner recommendation, a second
               pneumococcal immunization may be given after 5
               years following the first pneumococcal
               immunization, unless medically contraindicated or
               the resident or the resident's legal representative
               refuses the second immunization.




               This REQUIREMENT is not met as evidenced
               by:
               Based on medical record review and staff
               interview, the facility did not ensure that each
               resident was offered an influenza and
               pneumococcal immunizations between October 1
               through March 31 annually, unless it is medically
               contraindicated or the resident has been already
               immunized during this time period. The facility did
               not ensure before offering the influenza and
               pneumococcal immunizations that each resident
               or their legal representative received education
               regarding the benefits and potential side effects

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 16 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 Continued From page 16                                                       F 334
               of the immunization for 3 (#'s 8, 23 and 27) of 10
               residents. Specifically, the facility did not ensure
               there was documentation of refusal or
               acceptance of the pneumococcal immunization
               when it was offered or that education was
               provided on the benefits and potential side effects
               of the pneumococcal immunization for one
               resident (#8) and did not ensure that one resident
               (#23) was offered the influenza immunization
               between the dates of October 1 and March 31.
               The facility did not ensure, the resident was
               offered the pneumococcal vaccine after
               admission, and did not ensure that one resident
               (#27) or their legal representative was provided
               with education before offering the influenza and
               pneumococcal immunizations regarding the
               benefits and potential side effects of the
               immunization. This resulted in no actual harm
               with the potential for minimal harm that is not
               immediate jeopardy. This is evidenced by:

               Resident #8
               The resident was offered the pneumococcal
               immunization on admission with no evidence of
               education regarding its benefits and potential
               side effects or documentation of whether the
               resident refused or accepted the pneumococcal
               immunization at the time it was offered.

               The resident was admitted to the facility on
               10/25/04 with diagnoses of cerebrovascular
               accident, congestive heart failure and diabetes
               mellitis. The Minimum Data Set (MDS) dated
               5/4/08 assessed the resident as having no short
               term or long term memory problems and as
               having independent decision-making skills.

               Upon medical record review, the Immunization
               Record noted that the resident had been offered

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 17 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 Continued From page 17                                                       F 334
               the pneumococcal vaccination on 4/30/08. There
               was no documentation on this record regarding
               the benefits and potential side effects of the
               pneumococcal immunization having been
               reviewed with this resident at the time that it was
               offered or any documentation as to whether the
               resident refused or accepted this immunization
               after it was offered.

               In an interview with the Registered Nurse Unit
               Manager (RNUM) on 8/28/08 at 9:20 am, she
               stated that she could find no documented
               evidence of whether the resident had refused or
               accepted the pneumococcal immunization when it
               was offered on admission or that education was
               provided to the resident regarding the benefits
               and potential side effects of pneumococcal
               immunization.

               Resident #23
               The facility did not ensure that the resident was
               offered the influenza immunization between the
               dates of October 1 through March 31 or the
               pneumococcal immunization after admission.

               The resident was admitted to the facility on 2/1/08
               with diagnoses of cerebrovascular accident,
               seizure disorder and hypothyroidism. The
               Minimum Data Set (MDS) dated 8/7/08 assessed
               the resident as having no short-term or long-term
               memory problems and moderately impaired
               decision-making skills.

               Upon medical record review, there was no
               evidence of an Immunization Record or that the
               resident was ever offered the influenza and
               pneumococcal immunizations following
               admission.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 18 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 Continued From page 18                                                       F 334
               In an interview with the Registered Unit Nurse
               Manager on 8/28/08 at 9:20 am, she stated that
               she did not know if the resident had received the
               immunizations prior to her admission and that the
               facility was still waiting for information to be sent
               over from her community physician on her
               immunization history. She stated that no
               influenza immunization or pneumonia
               immunization had been offered to the resident at
               the facility since admission. She stated that no
               education had been offered to the resident in
               relation to the benefits and potential side effects
               of the influenza and pneumococcal
               immunizations.

               Resident #27
               The facility did not ensure that the resident or her
               legal representative was provided with education
               before offering the influenza and pneumococcal
               immunizations regarding the benefits and
               potential side effects of the immunizations.

               The resident was admitted to the facility on
               10/25/04 with diagnoses of cerebrovascular
               accident, hypertension, and diabetes mellitis.
               The MDS dated 8/16/08 assessed the resident as
               having short term memory problems, intact long
               term memory and modified independence in
               decision-making skills in new situations only.

               Upon medical record review, the immunization
               record sheet identified that the resident received
               the influenza immunization on 11/8/07 and the
               pneumococcal immunization on 12/1/04. There
               was no evidence that education had been offered
               to the resident or her legal representative
               regarding the benefits and potential side effects
               of these immunizations.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 19 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 334 Continued From page 19                                                       F 334
               In an interview with the Registered Unit Nurse
               Manager on 8/28/08 at 9:20 am, she stated she
               was unable to find any evidence that education
               was provided to the resident regarding the
               benefits and potential side effects of the influenza
               and pneumococcal immunizations after they were
               offered.

            10 NYCRR 415.19
      F 386 483.40(b) PHYSICIAN VISITS                                                   F 386                                                           9/19/08
      SS=E
               The physician must review the resident's total
               program of care, including medications and
               treatments, at each visit required by paragraph (c)
               of this section; write, sign, and date progress
               notes at each visit; and sign and date all orders
               with the exception of influenza and pneumococcal
               polysaccharide vaccines, which may be
               administered per physician-approved facility
               policy after an assessment for contraindications.


               This REQUIREMENT is not met as evidenced
               by:
               Based on medical record review and staff
               interview during the standard recertification
               survey, the facility did not ensure that the
               physician reviewed the resident's total program of
               care, including medications and treatments, at
               each visit and signs and dates all orders for
                4 (#'s 8, 15, 23 and 27) of 10 residents.
               Specifically, the facility did not ensure that the
               physician dated interim telephone orders when
               signed for 4 residents (#'s 8, 15, 23 and 27). This
               resulted in no actual harm with the potential for
               minimal harm that is not immediate jeopardy.
               This is evidenced by:

               Resident #8

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 20 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 386 Continued From page 20                                                       F 386
               The facility did not ensure that the physician
               dated interim telephone orders for the resident.

               The resident was admitted to the facility on
               4/30/08 with diagnoses of hypertension, venous
               stasis ulcers and dyslipidemia. The Minimum
               Data Set (MDS) dated 7/12/08 assessed the
               resident as having intact short and long term
               memory and independent decision making skills.

               Interim physician telephone orders written on
               7/30/08, 8/5/08, and 8/11/08 were all signed by
               the doctor, but were undated when signed.

               In an interview with the Registered Nurse Unit
               Manager (RNUM) on 8/27/08 at 10:07 am, she
               stated that the physician was at the facility on
               Mondays, Wednesdays, Fridays and on the
               weekends. She stated that she never really
               thought anything about the physician not dating
               orders when he signed them because he was at
               the facility so frequently. She stated that because
               of this, she never thought there had been any
               lapse in the doctor signing the orders from the
               time that they were written. She reported that she
               was unaware of any specific time period of when
               telephone orders needed to be signed after they
               were written and of the need for the doctor to date
               the orders when he was signing them. She also
               stated she was unaware of any regulation for this.

               Resident # 15
               The facility did not ensure that the physician
               dated interim telephone orders for the resident.

               The resident was admitted to the facility on
               11/1/03 with diagnoses of congestive heart
               failure, hypertension and diabetes mellitis. The
               MDS dated 5/15/08 assessed the resident as

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 21 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 386 Continued From page 21                                                       F 386
               having short term memory problems, intact long
               term memory, and modified independence in
               decision making skills in new situations only.

               Interim physician telephone orders written by
               nursing staff on 6/16/08, 6/24/08, 6/29/08,
               7/21/08, 7/24/08, 7/28/08, 7/29/08, 8/13/08 and
               8/14/08 were all signed by the doctor, but were
               undated when signed.

               In an interview with the Registered Unit Nurse
               Manager on 8/27/08 at 10:07 am, she stated that
               the physician was at the facility on Mondays,
               Wednesdays, Fridays and on the weekend. She
               stated that she never really thought anything
               about the physician not dating orders when he
               signed them because he was at the facility so
               frequently. She stated that because of this, she
               never thought there had been any lapse in the
               doctor signing the orders from the time that they
               were written. She reported that she was unaware
               of any specific time period of when telephone
               orders needed to be signed after they were
               written and of the need for the doctor to date the
               orders when he was signing them. She also
               stated she was unaware of any regulation for this.

               Resident #23
               The facility did not ensure that the physician
               dated interim telephone orders when signed for
               the resident.

               The resident was admitted to the facility on 2/1/08
               with diagnoses of hypertension, degenerative joint
               disease and glaucoma. The MDS dated 8/7/08
               assessed the resident as having intact short term
               and long term memory and as having moderately
               impaired decision making skills.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 22 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 386 Continued From page 22                                                       F 386
               Interim physician telephone orders written by
               nursing staff on 7/10/08, 7/11/08, 7/21/08 and
               8/19/08 were all signed by the doctor, but were
               undated when signed.

               In an interview with the Registered Unit Nurse
               Manager on 8/27/08 at 10:07 am, she stated that
               the physician was at the facility on Mondays,
               Wednesdays, Fridays and on the weekend. She
               stated that she never really thought anything
               about the physician not dating orders when he
               signed them because he was at the facility so
               frequently. She stated that because of this, she
               never thought there had been any lapse in the
               doctor signing the orders from the time that they
               were written. She reported that she was unaware
               of any specific time period of when telephone
               orders needed to be signed after they were
               written and of the need for the doctor to date the
               orders when he was signing them. She also
               stated she was unaware of any regulation for this.

               Resident #27
               The facility did not ensure that the physician
               dated interim telephone orders for the resident.

               The resident was admitted to the facility on
               10/25/04 with diagnoses of anemia, hypertension
               and congestive heart failure. The MDS dated
               8/16/08 assessed the resident as having impaired
               short term memory, intact long term memory and
               modified decision making skills in new situations
               only.

               Interim physician telephone orders written by
               nursing staff on 8/13/08, 8/15/08, 8/14/08,
               8/19/08 and 8/21/08 were all signed by the doctor,
               but were undated when signed.


FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 23 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 386 Continued From page 23                                                       F 386
               In an interview with the Registered Unit Nurse
               Manager on 8/27/08, at 10:07 am, she stated that
               the physician is here on Mondays, Wednesdays,
               Fridays and on the weekend. She stated that she
               never really thought anything about the physician
               not dating orders when he signed them because
               he was at the facility so frequently. She stated
               that because of this, she never thought there had
               been any lapse in the doctor signing the orders
               from the time that they were written. She
               reported that she was unaware of any specific
               time period of when telephone orders needed to
               be signed after they were written and of the need
               for the doctor to date the orders when he was
               signing them. She also stated she was unaware
               of any regulation for this.

            10 NYCRR 415.15 (b)(2)(iii)
      F 441 483.65(a) INFECTION CONTROL                                                  F 441                                                           9/19/08
      SS=E
               The facility must establish and maintain an
               infection control program designed to provide a
               safe, sanitary, and comfortable environment and
               to prevent the development and transmission of
               disease and infection. The facility must establish
               an infection control program under which it
               investigates, controls, and prevents infections in
               the facility; decides what procedures, such as
               isolation should be applied to an individual
               resident; and maintains a record of incidents and
               corrective actions related to infections.


               This REQUIREMENT is not met as evidenced
               by:
               Based on medical record review and staff
               interview, the facility did not ensure that it
               established and maintained an infection control
               program designed to provide a safe, sanitary and

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 24 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 441 Continued From page 24                                                       F 441
               comfortable environment and to prevent the
               development and transmission of disease and
               infection for 2 (#'s 8 and 23) of 10 residents.
               Specifically, the facility did not ensure that a two
               step purified protein derivative (ppd) test, used to
               test for tuberculosis, was completed after
               admission for one resident (#8) and did not
               ensure that a timely two step ppd test was
               completed on another resident (#23) after
               admission. This resulted in no actual harm with
               the potential for minimal harm that is not
               immediate jeopardy. This is evidenced by:
               Resident #8
               The facility did not ensure that a two step ppd was
               completed after admission for the resident

               The resident was admitted on 4/30/08 with
               diagnoses of hypertension, venous stasis ulcers,
               and hypertension. The Minimum Data Set (MDS)
               dated 7/12/08 assessed the resident as having no
               short term or long term memory problems and as
               having independent decision making skills.

               Upon medical record review, the resident was
               found to have no immunization record in her
               chart. There was no evidence in the medical
               record that the resident had received a ppd test
               after admission.

               The resident's admission physician's orders dated
               4/30/08 wrote "Mantoux testing if applicable".

               In an interview with the Registered Unit Nurse
               Manager on 8/28/08 at 9:20 am, she stated that
               she could find no evidence that a ppd was ever
               done for this resident and stated that therefore,
               the resident had never received a ppd after being
               admitted to the facility (approximately 6 months
               ago).

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 25 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 441 Continued From page 25                                                       F 441

               In an interview with the Staff Development
               Coordinator on 8/28/08 at 11:25 am, she stated
               that ppd testing is supposed to be done at the
               time of admission and then ten to fourteen days
               later. She stated that the facility has no formally
               written policy on ppd testing, but that they just
               know they have to do it in the time frame she
               identified above. She stated that this is in their
               admission orders also, but when that was
               reviewed with her, she agreed that it was vague
               and that she would have to follow up with the
               Nurse Managers on this.

               Resident #23
               The facility did not ensure that a timely two step
               ppd was completed for the resident after
               admission.

               The resident was admitted on 2/1/08 with
               diagnoses of cerebrovascular disease, seizure
               disorder, and degenerative joint disease. The
               MDS dated 8/7/08 assessed the resident as
               having no short term or long term memory
               problems and as having moderately impaired
               decision making skills.

               Upon medical record review, the immunization
               record sheet revealed that the resident did not
               receive her first step of the ppd testing until
               2/29/08 (28 days after admission).

               The resident's admission physician orders dated
               2/3/08 wrote "Mantoux testing if applicable".

               In an interview with the Registered Unit Nurse
               Manager on 8/28/08 at 8:30 am, she stated that
               after looking into it, she determined that this
               resident's ppd testing was done late and did not

FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 26 of 27
                                                                                                                                              PRINTED: 11/20/2008
  DEPARTMENT OF HEALTH AND HUMAN SERVICES                                                                                                       FORM APPROVED
  CENTERS FOR MEDICARE & MEDICAID SERVICES                                                                                                   OMB NO. 0938-0391
 STATEMENT OF DEFICIENCIES                 (X1) PROVIDER/SUPPLIER/CLIA                (X2) MULTIPLE CONSTRUCTION                          (X3) DATE SURVEY
 AND PLAN OF CORRECTION                         IDENTIFICATION NUMBER:                                                                        COMPLETED
                                                                                      A. BUILDING         ______________________

                                                                                      B. WING _____________________________
                                                          335497                                                                                  08/28/2008
  NAME OF PROVIDER OR SUPPLIER                                                              STREET ADDRESS, CITY, STATE, ZIP CODE
                                                                                                8290 STATE RT 69
  EASTERN STAR HOME AND INFIRMAR
                                                                                                ORISKANY, NY 13424

    (X4) ID                SUMMARY STATEMENT OF DEFICIENCIES                            ID                      PROVIDER'S PLAN OF CORRECTION                 (X5)
    PREFIX             (EACH DEFICIENCY MUST BE PRECEDED BY FULL                      PREFIX                 (EACH CORRECTIVE ACTION SHOULD BE            COMPLETION
                       REGULATORY OR LSC IDENTIFYING INFORMATION)                                           CROSS-REFERENCED TO THE APPROPRIATE              DATE
     TAG                                                                               TAG
                                                                                                                         DEFICIENCY)


      F 441 Continued From page 26                                                       F 441
               know why this occurred. She stated that she had
               always thought that typically ppd testing is done
               with nursing home residents within 24-48 hours of
               admission and then again 14 days later for the
               second step.

               In an interview with the Staff Development
               Coordinator on 8/28/08 at 11:25 am, she stated
               that ppd testing is supposed to be done at the
               time of admission and then ten to fourteen days
               later. She stated that the facility has no formally
               written policy on pdd testing, but that they just
               know they have to do it in the time frame she
               identified above. She stated that this is in their
               admission orders also, but when that was
               reviewed with her, she agreed that it was vague
               and that she would have to follow up with the
               Nurse Managers on this.

               10 NYCRR 415.19 (a)(1-3)




FORM CMS-2567(02-99) Previous Versions Obsolete                    Event ID: MM8P11            Facility ID: 0624                     If continuation sheet Page 27 of 27
 Department of Health and Human Services                                                                                                                                      Form Approved
 Centers for Medicare & Medicaid Services                                                                                                                                     OMB NO. 0938-0390

                                                                                      Post-Certification Revisit Report
Public reporting for this collection of information is estimated to average 10 minutes per response, including time for reviewing instructions, searching existing data sources, gathering and
maintaining data needed, and completing and reviewing the collection of information. Send comments regarding this burden estimate or any other aspect of this collection of information
including suggestions for reducing the burden, to CMS, Office of Financial Management, P.O. Box 26684, Baltimore, MD 21207; and to the Office of Management and Budget, Paperwork
Reduction Project (0938-0390), Washington, D.C. 20503.


 (Y1)      Provider / Supplier / CLIA /                                  (Y2) Multiple Construction                                                                           (Y3) Date of Revisit
           Identification Number                                               A. Building
                                                                                                     01 - BUILDING                                                                    11/4/2008
          335497                                                                 B. Wing

 Name of Facility                                                                                                  Street Address, City, State, Zip Code

    EASTERN STAR HOME AND INFIRMAR                                                                                     8290 STATE RT 69
                                                                                                                       ORISKANY, NY 13424
This report is completed by a qualified State surveyor for the Medicare, Medicaid and/or Clinical Laboratory Improvement Amendments program, to show those deficiencies previously
reported on the CMS-2567, Statement of Deficiencies and Plan of Correction that have been corrected and the date such corrective action was accomplished. Each deficiency should be
fully identified using either the regulation or LSC provision number and the identification prefix code previously shown on the CMS-2567 (prefix codes shown to the left of each
requirement on the survey report form).




(Y4)     Item                                (Y5)      Date            (Y4)    Item                                 (Y5)     Date            (Y4)   Item                            (Y5)         Date

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                    10/27/2008                ID Prefix                                    10/27/2008                 ID Prefix

         Reg. # NFPA 101                                      0050               Reg. # NFPA 101                                      0061              Reg. #                                             ZZZZ
           LSC K0050                                                               LSC K0061                                                               LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC

                                                    Correction                                                             Correction                                                             Correction
                                                    Completed                                                              Completed                                                              Completed
       ID Prefix                                                              ID Prefix                                                               ID Prefix

         Reg. #                                               ZZZZ               Reg. #                                               ZZZZ              Reg. #                                             ZZZZ
           LSC                                                                     LSC                                                                     LSC




 Reviewed By                         Reviewed By                         Date:                     Signature of Surveyor:                                                             Date:

 State Agency

 Reviewed By                         Reviewed By                         Date:                     Signature of Surveyor:                                                             Date:
 CMS RO

  Followup to Survey Completed on:                                                                      Check for any Uncorrected Deficiencies. Was a Summary of
                                                                                                          Uncorrected Deficiencies (CMS-2567) Sent to the Facility?
                            8/28/2008                                                                                                                                                   YES        NO

 Form CMS - 2567B (9-92)                                                                           Page 1 of 1                                                      Event ID:       MM8P22

				
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Description: Dental Supplier Financial Statement document sample