Katherine Luther Residential Health Care and Rehabilitation Center

Based on observation, staff interview, and record review conducted during the standard survey, it was determined for 3 of 9 residents reviewed for pressure ulcers (Residents #12, 15 and 16), the facility did not ensure residents with pressure ulcers received the necessary treatment and services to promote healing. Specifically for Residents #12, 15, and 16 there was no assessment of the newly developed pressure ulcers by a qualified person in a timely manner, and reassessment for pressure relieving devices was not done in a timely manner. This resulted in actual harm for Residents #12, 15, and 16, that is not immediate jeopardy.
Findings include:

1) Resident #16 has diagnoses which include cardiomyopathy, congestive heart failure, and hypertension.

The Minimum Data Set assessment (MDS) dated February 9, 2011 documented the resident had short and long term memory impairment with moderately impaired cognition. This assessment documented the resident had pressure ulcers, was frequently incontinent, and needed limited assistance of one for bed mobility.

The comprehensive care plan (CCP) dated February 23, 2011, documented the resident had on open area on the left buttock, and that she was non-compliant with positioning, going back to bed, and being changed. The CCP did not address alternate pressure reduction strategies in relation to the resident's moderately impaired cognition, short term and long term memory impairment. The CCP dated March 25, 2011 documented the area on the resident's left buttock was healed. The CCP dated April 4, 2011, documented the resident was at high/moderate risk for developing pressure ulcers, and had a gel (a pressure distribution cushion) cushion in her wheelchair. An update to the CCP, dated May, 2011, documented "confusion noted on 3-11 shift periodically" there were no additional interventions related to this update.

A social service progress note dated May 16, 2011 documented an entry dated May 13, 2011, "Confusion noted with resident on 3-11 shift."

A licensed practical nurse (LPN) documented in the progress notes dated May 17, 2011, "Resident continues with periods of increased confusion."

The licensed practical nurse's (LPN) note dated May 19, 2011, documented the resident had a new area which measured 4.3 centimeters (cm) x 2.3 cm on the left lower buttock. An order to treat with RepliCare dressing (promotes wound healing), change every 5 days and as needed was obtained from the physician by the LPN.

The LPN documented on the Wound Measurement Sheet dated May 19, 2011 the area on the resident's left lower buttock was a Stage II pressure ulcer measuring 4.3 cm x 2.3 cm, with a wound bed of pink granulation tissue.

The registered nurse (RN) wound nurse's note dated May 20, 2011, did not include documentation regarding the pressure ulcer on the resident's left lower buttock.

A May 21, 2011 progress note entry by an LPN, documented the resident was noted with periods of increased confusion.

The unit RN recorded on the Wound Measurement Sheet dated May 24, 2011, Stage II pressure ulcer on the resident's left lower buttock measuring 4.3 cm x 2.3 cm, with a wound bed of pink granulation tissue.

The May 24, 2011 Physician Progress note documented the resident was seen as requested by staff. The staff revealed that family members were concerned because their mother had been increasingly confused and was no longer able to transfer from the chair to the bed and had not been cooperating with activities. "I am going to go ahead and discontinue the Librax (combination drug containing benzodiazepines- an antianxiety medication), that could have been a culprit."

The Physician's orders dated May 24, 2011 documented an order to discontinue Librax 1 capsule by mouth every 12 hours, this medication was initiated on April 22, 2011.

The May 26, 2011, RN wound nurse's note documented the resident had a Stage II pressure ulcer on the lower left buttock, and the treatment order changed to Solosite (a gel used to promote healing) with a Primapore dressing (an absorbant dressing) every day. This note recorded the resident had a cushion (did not specify the type) in the chair, and that the resident was non-compliant at times with going back to bed in the afternoon. The RN's note did not address alternate strategies or pressure reduction interventions for when the resident refused to return to bed in the afternoon or experienced increased confusion.

The Wound Measurement Guidelines form (completed by the RN) dated May 31, 2011, documented the pressure ulcer measured 5 cm x 4 cm with 10 % yellow slough (dead skin separated from surrounding tissue) and "bloody drainage." The treatment was changed to wash with normal saline and apply Bactroban (antibacterial cream) daily.

The physician note, dated May 31, 2011, documented the resident had a 3.5 cm x 3.5 cm pressure ulcer with no slough, "clean base." This note documented the physician discussed with staff to find a cushion for her seat so the ulcer "did not get more pressure."

Review of the CCP revealed no change in the cushion used in the resident's wheelchair, or any rationale for not changing the cushion.

The physician order dated June 2, 2011 documented to cleanse the pressure ulcer with normal saline and apply Santyl (an enzymatic ointment used to remove dead tissue) and cover with a Primapore dressing.

Per the RN wound care nurse's note, documented on June 3, 2011, the skin team had seen the resident on June 2, 2011. The note recorded the pressure ulcer had a scant amount of drainage, yellow slough was present (no percentage given), and the treatment was changed to Santyl, with a Primapore dressing. The note recorded the resident had a cushion for her chair (no type specified) and was non-compliant at times with going back to bed in the afternoon. The RN wound nurse documented the physician had spoken with the resident regarding the importance of going back to bed in the afternoon to offload the pressure ulcer, "resident had been slightly more agreeable to this." Will continue to re-approach when she does refuse. The RN's note did not address alternate strategies or pressure reduction interventions for when the resident refused to return to bed in the afternoon or experienced increased confusion.

The Wound Measurement Guidelines form dated June 6, 2011, documented the resident's left buttock pressure ulcer measured 4 cm x 3.8 cm with 10 % yellow slough and "bloody drainage."

The RN wound care nurse's note dated June 9, 2011, documented the resident's Stage II pressure ulcer had yellow slough present with a scant amount of serosanguineous drainage. The note recorded the resident had a gel cushion, and was non-compliant at times with going back to bed in the afternoon. The note did not address alternate interventions for pressure reduction if the resident was non-compliant with returning to bed in the afternoon or experienced increased confusion.

There was no documented evidence of a change in the cushion used in the resident's wheelchair, or rationale for not changing it.

The Wound Measurement Guidelines form dated June 14, 2011, documented the pressure ulcer measured 4 cm x 4 cm with yellow black slough covering 50% of the wound bed, and "bloody drainage."

The RN wound nurse note dated June 16, 2011 documented the resident's pressure ulcer was now a Stage III, with a moderate amount of yellow slough present, and a scant amount of serosanguineous drainage. Continue treatment was noted. This note documented the resident had a gel cushion in her chair and was noncompliant with going back to bed in the afternoon. This note documented the resident was frequently refusing to go back to bed, and stated she did not like to go back to bed, she spent enough time there at night. The note did not address alternate interventions for pressure reduction if the resident was non-compliant with returning to bed in the afternoon or experienced increased confusion.

The Wound Measurement Guidelines form dated June 21, 2011, documented the Stage III pressure ulcer measured 4 cm x 4 cm x 0.2 cm with 50% yellow black slough, and bloody drainage.

The physician note, dated June 21, 2011, documented the resident had a 4 cm size "deep" ulcer" "not up to the bone" with the base showing slough and "color" on her left buttock The note documented the resident's pressure ulcer was secondary to "persistent seated position. Discouraged her from doing that." Will send her to the wound clinic.

The Wound Measurement Guidelines form dated June 28, 2011, documented the pressure ulcer measured 5 cm x 4.2 cm with 50% black slough, and bloody drainage.

A nursing note dated June 30, 2011, documented the resident was admitted to the hospital for debridement of the "Stage III" pressure ulcer.

A nursing note dated July 1, 2011, documented the resident returned from the hospital.

The Readmission History and Physical, dated July 1, 2011, documented the resident was treated at the hospital for the pressure ulcer on her left buttock. This report noted she had sharp debridement of the pressure ulcer while under anesthesia.

The Wound Measurement Guidelines form dated July 1, 2011, documented the resident's pressure ulcer on the left lower buttock measured 3 cm x 3 cm x 4 cm (depth) with a red wound bed, and a wound vac (a negative pressure device applied to the wound to promote healing) was in place.

The Wound Measurement Guidelines form dated July 6, 2011, documented the pressure ulcer was 2.4 cm x 3.2 cm x 2 cm with tunneling at 2 PM of 5 cm and at 6 PM of 4 cm, there was black eschar (dead tissue) on the side of the wound bed and less then 10% "yellow" in the base of the wound bed. There was a small amount of "bloody drainage" present.

The Individualized Daily Resident Care Card dated July 6, 2011, documented the resident was to have a Roho (air flotation cushion) cushion in the wheelchair.

The physical therapy note dated July 7, 2011, documented, per recommendation of the skin team, a Roho cushion was issued due to the pressure ulcer on the resident's left
buttock.

The Physicians Progress Note, dated July 12, 2011 documented the resident was complaining again of some abdominal cramps and the plan was to start Bentyl (anti-spasmodic) to see whether it would help with the abdominal cramps.

The Physician's orders dated July 12, 2011 documented an order for the resident to receive Bentyl 10 mg by mouth twice per day.

The Physicians Progress Note, dated July 26, 2011 documented that the resident had complained of some abdominal cramps. " I gave her Bentyl and it appeared to have helped, but the patient developed some confusion so it has been discontinued.

The nursing note dated August 16,2011, documented the resident was scheduled for surgery on August 22, 2011 for surgical wound closure.

The surveyor interviewed the physical therapist (PT) on August 16,2001 at 12:30 PM. She stated her records showed the resident was issued a gel cushion for her wheelchair in December 2010, and a Roho cushion on July 7, 2011. The PT said cushions for chairs and wheelchairs were issued by the physical therapy department.

The surveyor interviewed the occupational therapist on August 16, 2011 at 12:30 PM; she stated she goes on wound rounds with the team. She stated the RN wound nurse was the one who told therapy what she wanted for the residents. The OT stated she then relayed that information to the PT, who then issued the cushions.

The surveyor observed the resident on August 17, 2011 at 9:40 AM during the pressure ulcer dressing change. The pressure ulcer was measured by the RN treatment nurse and was 3 cm x 4 cm x 4.1 cm (depth). The wound bed was granulation tissue with dark blue areas. The surrounding tissue was dusky blue, and the wound edges were macerated.

The surveyor interviewed the RN Unit Manager on August 18, 2011 at 11:50 AM; she stated the nurse who found the open areas on the resident's left buttock should have informed an RN. She said the LPN filled out the Wound Measurement Guidelines form, and the RN does not re-measure the pressure ulcer. The RN stated the LPNs cannot stage a pressure ulcer.

The surveyor interviewed the RN wound nurse on August 18, 2011 at 12:40 PM. She stated the skin team looks at pressure ulcers weekly. The team included the RN wound nurse, the unit treatment nurse (may be RN or LPN), PT or OT, and the dietitian. She said the team meets and looks at the pressure ulcers' overall appearance, and assesses related factors such as pressure relief, clothing, toileting, and supplements. The RN wound nurse stated she did not measure pressure ulcers on rounds, that the unit nurse (RN or LPN) did that preferably the day before rounds. She said when a pressure was newly found, there should be an assessment by an RN in the progress notes, in addition to the Wound Measurement Guidelines form (which is filled out by the nurse who initially sees the pressure ulcer, either an LPN or RN).

The surveyor interviewed the RN wound nurse on August 18, 2011 at 3:30 PM. She stated if she did not document a specific type of cushion, then it was a 4 inch ultra foam cushion. She said the resident refused changes, staff might have offered a different cushion and the resident refused. The RN was unable to provide documentation to support this.

The surveyor interviewed the RN Unit Manager on August 19, 2011 at 11 AM. She stated the resident had recurrent pressure ulcers and non-compliance with pressure relief was the reason. She said the resident was set in her ways and the pressure ulcer deteriorated as a result of the resident's non-compliance.

The surveyor interviewed with the Director of Nursing on August 19, 2011, at 12:45 PM. The Director of Nursing stated the expectation was that an RN would assess a new pressure ulcer and document the same. She said the Wound Measurement and Guidelines form was supposed to be data collection, and looked at the information as a description of the pressure ulcer. The DON stated if the pressure ulcer had any change, the LPN was to notify the RN. She said they had recently changed the form to include positioning and pressure relief provided.

In summary, the resident experienced actual harm as her pressure ulcer deteriorated, resulting in a hospitalization for surgical debridement, and was then scheduled for a second hospitalization for surgical closure of the pressure ulcer when the facility:
- did not change or reassess for effectiveness the wheelchair cushion from the time the pressure ulcer was found May 19, 2011, until July 7, 2011 (after surgical debridement and wound vac treatment, with noted deterioration of the pressure ulcer);
- did not have a qualified person (registered nurse, physician) assess the pressure ulcer for 5 days after it was found;
- did not provide alternate interventions for pressure reduction when the resident was non-compliant with returning to bed in the afternoon; and,
- did not address the resident's impaired cognition or increasing confusion as it related to her non-compliance with the plan of care.

2) Resident #12 had diagnoses including dementia and degenerative joint disease.

The comprehensive care plan (CCP) dated February 15, 2011, documented the resident was at risk for falls and had a wedge cushion in the wheelchair. The CCP dated July 20, 2011, documented the resident was at moderate risk for skin breakdown, due to dementia and incontinence. The CCP documented the resident should have a pressure relieving cushion when sitting in the wheelchair "i.e. Ultrafoam cushion."

The licensed practical nurse's (LPN) note dated August 1, 2011, documented the resident had a red blanchable area on the right buttocks, which measured 7 1/2 x 5 (no unit of measurement written), and a red blanchable area on the left buttock that measured 6 x 2 centimeters (cm). The note recorded the registered nurse (RN) was notified, and would inform the wound nurse in the morning that the resident needed to be seen.

The RN note, dated August 2, 2011 documented she was called to the room to "check areas" and redness was noted to the left hip, left lateral thigh, left ankle bone, left outer mid foot, and right hip. The areas were blanchable and barrier cream was applied," will continue to monitor areas." There were no entries to apply barrier cream to these areas on the August 2011 TAR (treatment administration record), no changes made to the CCP and no changes to the the Individualized Daily Resident Care Card (nurse aide care card) regarding the use or frequency of barrier cream to these areas.

There was no documented evidence the reddened areas on the resident's buttocks were seen by a person who was qualified to assess the areas(registered nurse, physician or nurse practitioner) from August 2, 2011, until August 11, 2011. There was no documented evidence the areas were treated with barrier cream, any other form of treatment or the results of any treatment.

The physician note, dated August 9, 2011, documented the resident had been seen and examined for redness of the scrotum. The documentation did not include an examination of the resident's buttocks.

The registered nurse note dated August 11, 2011, documented the resident had 3 Stage II pressure ulcers; 1 on the right buttock, 1 on the left buttock, and 1 on the coccyx. There was no documented assessment of the pressure ulcer areas (size, wound bed, drainage).

Physician's orders dated August 11, 2011 documented a telephone order was obtained by the LPN to treat the open areas on the coccyx, left and right buttocks: to cleanse the area, apply RepliCare (a type of wound dressing) and change every 5 days and as needed.

The LPN documented on the Wound Measurement form, dated August 11, 2011, regarding the Stage II pressure ulcers as follows:
- the coccyx measured 2 cm x 1 cm, with a pink wound bed;
- the right buttock measured 5 cm x 3 cm with a yellow/green "scab" covering 100% of the wound bed; and
- the left buttock measured 2 cm x 1.5 cm with a yellow/green "scab" covering 100% of the wound bed.
The treatment documented on this form for the 3 pressure ulcers was RepliCare every 5 days, and as needed. This form documented the resident was on an air mattress, there was no documentation regarding the type of cushion the resident used in his wheelchair.

The resident's Minimum Data Set (MDS) assessment, dated August 11, 2011, documented the resident's cognition was severely impaired, he had short term and long term memory impairment.

On August 11, 2011, the CCP documented the resident had Stage II pressure ulcers on his coccyx, his right buttock, and his left buttock. The only documented change in planned interventions was the RepliCare dressing.

The surveyor observed the resident's pressure ulcers on August 16, 2011 at 10:25 AM during the dressing change. The resident was lying on the bed, with no dressing on the resident's buttocks or coccyx. The resident's buttocks were dusky red and excoriated. There were multiple open areas with 100% yellow slough and the coccyx pressure area was 100% green slough. The LPN measured 1 area on each buttock and the area on the coccyx. She did not measure the dusky red excoriation on both buttocks. The LPN applied RepliCare, using 2 dressings that came together at the coccyx pressure ulcer. The RepliCare did not cover the entire area of excoriation.

The surveyor interviewed the LPN immediately after the dressing change observation; she stated that she was going to fill out the Wound Measurement form for the resident. She said she wound rounds would be in 2 days (August 18, 2011), and she always filled out this form 1 or 2 days before the skin team made wound rounds.

The LPN documented on the Wound Measurement form, dated August 16, 2011, regarding the Stage II pressure ulcers as follows:
- the coccyx measurements were unchanged (from August 11, 2011) and the wound bed was 100% slough (dead tissue);
- the right buttock measured 4.0 cm x 2.7 cm with 100% yellow slough in the wound bed; and
- the left buttock measured 2.2 cm x 1.7 cm with 100% yellow slough in the wound bed.
The assessment was incomplete, as there was no documentation regarding the type of cushion used in the wheelchair in the area titled, "mattress/cushion", or of a change in treatment on the August 16, 2011 Wound Measurement form.

The Daily Resident Care Card (used to direct the resident's care), dated August 16, 2011, documented the resident had a wedge cushion in the wheelchair.

The surveyor observed the resident in his wheel chair on August 16, 2011 at 11:45 AM; he was seated on a wedge cushion.

The surveyor interviewed the physical therapist (PT) on August 16, 2011 at 12:20 PM; she stated she had not been asked to evaluate the resident's cushion. The PT said she knew the resident had new pressure ulcers, and would not be surprised if he needed a different cushion. The PT provided the surveyor with the product information for the wedge cushion used by the resident. This information documented the cushion was a firm foam foundation covered by comfort foam, and provided a firm level seat.

The surveyor interviewed the occupational therapist (OT) on August 16, 2011 at 12:30 PM; she stated she goes with the skin team on wound rounds. The OT said she had not seen the resident's pressure ulcers, as the dressing was intact so the team did not remove it to assess the pressure ulcers. The OT stated the registered nurse (RN) wound nurse is the one who decides and/or requests an evaluation of resident's cushions or a change in cushion.

The surveyor interviewed the LPN on August 18, 2011 at 11:15 AM; she stated when a pressure ulcer is found an RN should be with the LPN, as she (the LPN) records the information on the Wound Measurement form. She said after that she (the LPN) looks at the pressure ulcers and records the information on the form every week. The LPN said the facility liked to have the same person looking at the pressure ulcers each week, so that there was continuity. If the pressure ulcer got better or worse, then the RN would be notified.

The surveyor interviewed the RN wound nurse on August 18, 2011, at 12:40 PM; she stated the skin team looks at pressure ulcers weekly. The team included the RN wound nurse, the unit treatment nurse (may be RN or LPN), PT or OT and the dietitian. She said the team meets and looks at the pressure ulcers overall appearance, and assesses related factors, such as pressure relief, clothing, toileting, and supplements. The RN wound nurse stated she did not measure pressure ulcers on the rounds, that the unit nurse (RN or LPN) did that preferably the day before rounds. She said when a pressure is newly found there should be an assessment by an RN in the progress notes, in addition to the Wound Measurement Guidelines form (which was filled out by the nurse who initially saw the pressure ulcer LPN or RN).

The surveyor interviewed the RN wound nurse on August 18, 2011 at 2:45 PM; she stated she had not seen the resident's pressure ulcer areas, and had not requested evaluation for a pressure relieving cushion. There was no further explanation offered.

The surveyor observed the resident on August 19, 2011 at 11 AM in his wheelchair in the hallway. He was sitting on a wedge cushion.

In summary the resident experienced harm, as the reddened areas on the resident's buttocks deteriorated from blanchable redness to unstageable pressure ulcers, and the facility:
- did not reassess the resident for pressure relief when in the wheelchair;
- did not have a qualified person assess or document an assessment of the resident's buttocks when they were observed to be red, or for 10 days after when the resident was found to have 3 Stage II pressure ulcers; and,
- did not notify the RN that the Stage II pressure areas were now unstageable, as they were covered with slough.

3) Resident #15 had the diagnoses of dementia, hypertension, congestive heart failure, and vitamin B-12 deficiency.

The comprehensive care plan (CCP) dated February 11, 2011, and updated August, 2011 documented the following problem, "Resident is at moderate risk for skin breakdown due to: dementia, decreased mobility and incontinence" with a goal of, "Maintain skin integrity, avoid skin traumas." There were no alternate interventions identified for when the resident was non-compliant with going back to be in the afternoon, or repositioning side-to-side.

The licensed practical nurse's (LPN) note dated May 2, 2011 documented the resident had a small open area to the right buttock measuring 1.2 centimeters (cm) x 1.0 cm.

The physician telephone order dated May 2, 2011 documented an order to apply a RepliCare dressing (used to promote wound healing) to the open area on the right buttock every 5 days and as needed until healed.

The unsigned Wound Measurement form dated May 2, 2011, documented the resident had a Stage II pressure ulcer on the right buttock, that measured 1.2 centimeters (cm) x 1 cm and was pink. The form recorded the resident had an Ultrafoam cushion in the wheelchair.

There was no documented evidence of an assessment of the new open area by a qualified person from May 2, 2011 until May 5, 2011.

The registered nurse (RN) wound nurse's note dated May 6, 2011, documented the resident was seen on skin rounds on May 5, 2011. This note recorded the resident had a Stage II pressure ulcer on the right buttock, which had a pink wound bed of granulation tissue. This note documented the resident would be approached to position side to side when in bed, to go back to bed in the afternoon, and had been non-compliant with this in the past. The note recorded the resident "currently refused this." The RN's note did not address the resident's dementia or any alternate interventions to be implemented when the resident was non-compliant with returning to bed in the afternoon or reposition side to side.

The unsigned Wound Measurement form dated May 11, 2011, documented the resident's pressure ulcer was 1 cm x 1 cm, with a closed pink tissue wound base, and was not blanchable.

The RN wound nurse's note dated May 12, 2011 documented the resident was not seen on wound rounds as the pressure ulcer dressing was not scheduled to be changed.

The unsigned May 16, 2011, Wound Measurement form documented, the pressure ulcer was a Stage II measuring 3 cm x 2 cm, was 60% purple pink in color with an "open base."

The RN wound nurse's note dated May 20, 2011 documented the pressure ulcer was Stage II, with pink granulation tissue, a moderate amount of serosanguineous drainage, and deep red erythema (redness) of surrounding tissue. This note documented the resident had a gel cushion in the wheelchair. (Eighteen days after the area was found, during which time it worsened, the resident was provided with alternate pressure relief from the cushion he was using before the pressure ulcer developed).

The unsigned Wound Measurement form, dated May 25, 2011, documented the resident had a Stage II pressure ulcer that measured 1.6 x 2 (no unit of measurement recorded), with pink/yellowish wound bed (no percentage recorded) and pink granulation tissue (no percentage recorded).

The Wound Measurement form, dated June 1, 2011, documented the pressure ulcer on the resident's right buttock was 2 x 2 (no unit of measurement recorded), the wound bed was 95% white slough (dead tissue) with 5% white edges. The form documented a gel cushion was used in the wheelchair.

Physician orders dated June 2, 2011 documented an order to cleanse the area on the right buttock with wound cleanser, apply Santyl (an enzyme that helps remove dead tissue from wounds to assist in healing), cover with a 2 x 2 Primapore (type of dressing) every day, and as needed.

The RN wound nurse's note dated, June 3, 2011, documented the resident's pressure ulcer was a Stage II, with pink granulation tissue present, a moderate amount of yellow slough, and a moderate amount of serosanguineous drainage present, "no erythema" (redness) present. The RN note documented the resident had been non-compliant with going to bed in the afternoon and side positioning in the past. This note recorded the resident was now "sometimes" agreeable to it. The RN's note did not address the resident's dementia or include any alternate interventions for when the resident was non-compliant with returning to bed in the afternoon, or repositioning side to side in bed.

The unsigned Wound Measurement form, dated June 6, 2011, documented the pressure ulcer was a Stage III, measured 2.2 cm x 2 cm, with 95% white slough in the wound bed; the surrounding tissue was "firm red rimmed."

The physician note, dated June 6, 2011, documented the resident had an area on his right buttock, which initially started as a blister. The note documented the ulcer was 1.5 cm, open with slough and drainage, surrounded by 4 cm of slightly warm, red induration. The assessment was an infected ulcer. The physician note recorded the resident would be started on Ceftin (an antibiotic) 250 milligrams (mg) by mouth for 10 days.

The RN wound nurse's note dated June 6, 2011, documented the resident's pressure ulcer on the right buttock was a Stage III, with:
- a moderate amount of yellow slough present;
- pink granulation present;
- a moderate amount of serosanguineous drainage present;
- slight erythema to surrounding tissue present; and
- induration present.
The RN's note documented the resident had been non-compliant with going to bed in the afternoon and side positioning in the past. This note recorded the resident was now sometimes agreeable to it, and had a gel cushion in the wheel chair. The RN's note did not address the resident's dementia or indicate any alternative pressure relieving strategies for when the resident was non-compliant with returning to bed and side positioning.

The unsigned Wound Measurement form, dated June 9, 2011, recorded the resident used a gel cushion in the wheelchair. (There was no documented assessment of the pressure ulcer dated June 9, 2011).

The Wound Measurement form dated June 14 - July 18, 2011, documented the resident had: a gel cushion in the wheelchair; a Stage III pressure ulcer on the right buttock, with 85 - 90% yellow or white slough in the wound bed; no pain, and the pressure ulcer measured as follows:
- June 14, 2011, 1.8 cm x 1.7 cm;
- June 20, 2011, 1.8 cm x 1 cm;
- June 27, 2011, 1 cm x 0.6 cm;
- July 5, 2011, 0.8 cm x 0.6 cm;
- July 12, 2011, 1.4 cm x 0.8 cm; and
- July 18, 2011, 1.2 cm x 1 cm.
This form documented on July 25, 2011, the pressure ulcer measured, 1 cm x 1 cm with 100% white slough.

The wound nurse's notes, dated June 16, 2011 - July 21, 2011, documented the resident had a gel cushion in the wheelchair, was non-compliant at times with going back to bed in the afternoons and side positioning when in bed. The wound nurse's note did not address the resident's dementia or any alternate interventions for when the resident was non-compliant with returning to bed in the afternoon, or side positioning in bed.

Physician orders, dated July 28, 2011, documented an order to cleanse the area on the right buttock with normal saline, apply Santyl and cover with Allevyn foam (a type of dressing) every day and as needed.

The Minimum Data Set (MDS) assessment dated August 3, 2011, documented the resident's cognitive skills for daily decision making were moderately impaired, his decisions were poor and cues/supervision were required. The assessment documented the resident required extensive assistance of one person to move in bed, turn side to side, or position his body.

The Wound Measurement form dated August 2 - 15, 2011, documented the Stage III pressure ulcer on the resident's right buttock had a wound bed that was 100% white slough, was tender and measured 1 cm x 1 cm x 0.8 cm. This form documented the resident had a gel cushion in the wheelchair. The surveyor observed the resident's pressure ulcer on August 17, 2011 at 10:10 AM, during the dressing change. The pressure ulcer measured approximately 1 cm x 0.8 cm, the wound bed was yellow/green with surrounding redness.

The physical therapy note dated August 19, 2011, documented the resident was given a Matrix cushion for the wheelchair, "to help reduce pressure on buttocks."

The Individualized Daily Resident Care Card dated August 19, 2011 documented the resident's ADL's (activities of daily living) as follows: the resident was non-ambulatory, transferred with the use of a stand-lift and 1 assist, propelled himself in a wheelchair, needed assistance of 1 person to reposition himself in bed, and was to be positioned in bed with a pillow to alleviate pressure on his buttock. The Care Card also documented the resident had a Matrix wheelchair cushion, was at moderate risk of skin breakdown and was to go back to bed in the afternoon.

The surveyor interviewed the RN Unit Manager on August 18, 2011, at 11:50 AM. The RN stated when a new pressure ulcer is found the nurse had to inform the RN. She said if the LPN measured the pressure ulcer, the RN did not have to measure it. The RN stated the LPN could fill out the wound measurement form.

The surveyor interviewed the RN wound nurse on August 18,2011 at 2:15 PM. She stated they did not always go and "throw everything in" when they first find a pressure ulcer. She said when the area was first found it was closed, so when the area opened, the facility provided a new cushion.

In an interview with the RN Unit Manager on August 19, 2011 at 11 AM, she stated the resident was not compliant with positioning, and going back to bed. She said this contributed to the development and worsening of the pressure ulcer.

In summary the resident experienced harm as his pressure ulcer worsened, then became non-healing when the facility:
- did not reassess the resident for pressure relief in the wheelchair; when he was known to be not consistently compliant with going to bed in the afternoon and side positioning when in bed;
- did not address the resident's impaired cognition as it related to his non-compliance with the plan of care or provide alternate interventions for pressure reduction; and,
- did not have a qualified person assess the resident's pressure ulcer for 3 days after it was found as an open wound.

10NYCRR 415.12(c)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not promote care for 3 of 27 current sampled residents (Residents #4, 19, and 22), and for 2 residents outside the sample (Residents #38 and 39), in a manner and in an environment that maintained or enhanced their dignity or respect. Specifically Residents #4, 38, and 39 were spoken to by staff in an undignified manner, Resident #19's left wheel on her wheelchair was soiled with multiple areas of dried matter, and Resident #22's padded arm rests on her wheelchair were soiled with multiple dried stains. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

Findings include:

1) Resident #4 had diagnoses including Alzheimer's dementia, anxiety, and depression.

The Minimum Data Set (MDS) assessment, dated August 11, 2011, documented the resident had severe cognitive impairment, usually understood others, and usually was able to be understood. The MDS assessment documented the resident required from limited assistance to extensive assistance from staff with activities of daily living (ADLs).

On August 18, 2011 at 8:55 AM, the resident was observed in the unit dining room seated at a table having breakfast. A certified nurse aide (CNA) was seated across from Resident #4 at the same table, and was assisting another resident with her meal. The CNA was overheard by a surveyor, as the CNA said to Resident #4, "try your pancakes honey." The CNA went over to assist Resident #4 and said, "you need to eat something. Here honey, pick up your fork. I know honey. You have to eat something."

When interviewed on August 18, 2011 at 1:20 PM, the same CNA, who fed the resident breakfast earlier, stated she had been told by staff residents should be addressed by their first names, and not to use other names to refer to them. The CNA said, "I know I'm not suppose to. At times, it's hard to remember."

When interviewed on August 18, 2011 at 2:15 PM, the unit social worker stated this was a dignity issue. She said residents should be referred to by their names.

2) Resident #22 had diagnoses including dementia, agitation, and depression.

The Minimum Data Set (MDS) assessment dated May 26, 2011, documented the resident had severe cognitive impairment, sometimes was able to understand others, and rarely/never was understood. The MDS assessment documented the resident required total assistance from staff for all activities of daily living (ADLs).

The comprehensive care plan (CCP) updated on June 9, 2011, documented the resident used a reclining back wheelchair, and required total assistance from staff for locomotion on and off the unit. The CCP documented the resident should be assured an enhanced level of dignity and self worth.

The Individualized Daily Resident Care Card dated August 10, 2011 (used by the certified nurse aides (CNAs) to provide care to the resident), documented the resident was non-ambulatory, and used a wheelchair propelled by staff.

On August 16, 2011 at 12:35 PM, the resident was observed in the unit dining room seated in her wheelchair at a table having lunch. The resident's wheelchair had padded arm rests on each side which were observed to be soiled, with multiple dried stains spattered all over them.

On August 17, 2011 at 8:20 AM, the resident was observed in the unit dining room seated in her wheelchair at a table having breakfast. The padded arm rests on both sides of the resident's wheelchair were observed to be soiled, with multiple dried stains spattered all over them.

The resident's primary CNA was interviewed on August 18, 2011 at 8:30 AM , feeding the resident breakfast in the unit dining room. When a surveyor asked the CNA about the condition of the resident's padded arm rests on her wheelchair, she said, "they are nasty, and have been like this for a while". The CNA said she thought physical therapy (PT) was responsible for cleaning the wheelchair arm rests. The CNA said, "I should take them. I should find out. I have neglected this."

When interviewed on August 18, 2011 at 12 PM, the unit social worker stated the wheelchair arm rests should have been washed, and it was inexcusable the arm rests had gotten so dirty.

In summary, the facility did not promote care for residents in a manner and in an environment that maintained or enhanced the resident's dignity and respect, as the resident's soiled and stained wheelchair arm rests were not cleaned in a timely manner.

3) Resident #39 had diagnoses of osteoarthritis and dementia.

The Minimum Data Set (MDS) assessment dated June 11, 2011, documented the resident had severely impaired cognition, used a wheelchair, and needed extensive assistance to move about the unit.

On August 16, 2011 at 1:30 PM, the resident was observed seated in a wheelchair outside of the Mapleview dining room propelling herself past the elevators. There was another resident seated in a wheelchair in front of the elevators and a surveyor was seated nearby. The registered nurse (RN) was observed to approach the resident from behind, placed her hands on the handgrips of the wheelchair and asked the resident in a loud, clear voice, "have they toileted you?" The resident responded to the question and the RN assisted the resident in moving towards her unit.

On August 17, 2011 at 3:00 PM, the social worker was interviewed and stated that asking a resident if she had been toileted where others could hear was a dignity issue. She also stated the resident should have been asked in a more private manner.

On August 19, 2011 at 9:50 AM, the RN was interviewed and stated that she should not have spoken loudly when she asked the resident if she had been toileted, because that was a dignity issue.

In summary, the facility did not ensure the resident was treated with dignity and respect when she was asked in front of others if she had been toileted.

10NYCRR 415.5(a)

Based on record review and staff interview conducted during the standard survey, it was determined the facilty did not ensure required notices were provided in a timely manner to 4 of 7 sampled residents who were were cut from Medicare in the last 4 months,(Residents #31, 32, 33, and 34). Specifically, there was no documented evidence notices were provided to Residents #32, 33, and 34, or to the residents' representative, and the notice provided to Resident #31's representative was provided 2 months late. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #31 was admitted in April 2011 with diagnoses including atrial fibrillation (irregular heartbeat) and dementia.

The Minimum Data Set dated July 27, 2011 documented the resident had moderately impaired cognition. The comprehensive care plan dated August 3, 2011, documented the resident had impaired cognition and poor short and long term memory.

An undated Advance Notice of Medicare Provider Non-Coverage documented Resident #31's last day of Medicare coverage was May 30, 2011. The document was signed by the resident's representative on August 1, 2011.

A Notice of Medicare Provider Non-Coverage Invalid Notice from the Medicare Intermediary dated August 13, 2011, documented no notice was provided to the Medicare Intermediary for review (after the resident's representative appealed the facility's decision to end Medicare coverage).

The Senior Director of Clinical Services responded in writing on August 17, 2011 that the facility recognized the error with the notice Of Non-Coverage.

When the Senior Director of Clinical Services was interviewed on August 18, 2011 at 10:40 AM, she stated she had been on vacation at the time the resident's Medicare coverage ended and she was aware of the concern about providing notice to the resident's representative.

The facility was unable to provide documented evidence the resident/resident's representative was notified in the timely manner of ending Medicare coverage.

2) Resident #32 was admitted to the facility in December 2010 with diagnoses of adjustment disorder and dementia.

The comprehensive care plan dated May 31, 2011, documented the resident had cognitive impairment, including impaired decision making ability, and long and short term memory loss.

The Minimum Data Set dated June 23, 2011, documented the resident's cognitive status was modified independence.

An undated Detailed Notice of Medicare Non-Coverage documented the resident's last day of Medicare coverage was July 7, 2011. The notice was not signed by either the resident or the resident's responsible party.

There was no documented evidence the resident's responsible party was notified that the resident's Medicare coverage was ending.

3) Resident #33 was admitted to the facility in June 2011 with diagnoses including acute respiratory failure and ischemic heart disease (inadequate blood supply to the heart).

The comprehensive care plan dated July 7, 2011, documented the resident was alert and oriented, with confusion at times.

The Minimum Data Set dated July 2, 2011, documented the resident's cognitive status was independent.

An undated Detailed Notice of Medicare Non-Coverage documented the resident's last day of Medicare coverage was July 10, 2011. The notice was not signed by either the resident or the resident's responsible party.

There was no documented evidence the resident's responsible party was notified that the resident's Medicare coverage was ending.

The Quality Assurance Analyst was interviewed on August 17, 2011 at 3:45 PM. She stated the facility routinely provided the non-coverage notice to the guarantor (the individual(s) responsible for assuring payment to the facility). She stated if the resident was not listed as the guarantor, the Interdisciplinary Team Coordinator called the guarantor (via telephone).

The Interdisciplinary Team Coordinator was interviewed on August 17, 2011 at 4 PM. She stated she routinely called the guarantor to advise the guarantor the resident's Medicare coverage was ending. When the Interdisciplinary Team Coordinator was interviewed at 4:25 PM, she stated she could not find evidence the notice of non-coverage was provided to Residents #32, 33, and 34.

There was no documented evidence required non-coverage notices were provided to the residents/responsible parties for Residents 32, 33, and 34.

In summary, there was no documented evidence required notices were provided to the 4 residents in a timely manner when they were cut from Medicare, as required.

10NYCRR 415.3(g)(2)

Based on observation, resident and staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure personal privacy was provided to residents during medical treatment and personal care for 2 of 27 current sampled residents reviewed for privacy concerns (Residents #12 and 16), and 1 resident outside the sample, Resident #37. Specifically, personal privacy was not provided to Residents #12 and 16 during medical treatment, and personal privacy was not consistently provided to Resident #37 during personal care. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #12 had diagnoses including dementia and degenerative joint disease.

The comprehensive care plan (CCP) dated July 20, 2011, documented the resident was at moderate risk for skin breakdown, due to dementia and incontinence.

The resident's Minimum Data Set (MDS) assessment, dated August 11, 2011, documented the resident's cognition was severely impaired.

The Wound Measurement form, dated August 16, 2011, documented the resident had Stage II pressure ulcers as follows:
- the coccyx measurements were unchanged (from August 11, 2011) and the wound bed was 100% slough (dead tissue);
- the right buttock measured 4.0 cm x 2.7 cm with 100% yellow slough in the wound bed; and
- the left buttock measured 2.2 cm x 1.7 cm with 100% yellow slough in the wound bed. The treatment documented on this form for the 3 pressure ulcers was RepliCare every 5 days, and as needed.

The surveyor observed the resident's pressure ulcers on August 16, 2011 form 10:25 AM to 10:35 AM, during a dressing change. The resident was lying on the bed, and there was no dressing on the resident's buttocks or coccyx. The resident's buttocks were dusky red and excoriated. There were multiple open areas with 100% yellow slough and the coccyx pressure area was 100% green slough. There was no sheet or blanket on the residents bed to cover him. The resident had no clothing on his body and was completely exposed throughout the observation. Present in the room during the observation were the licensed practical nurse (LPN), the certified nurse aide (CNA), the surveyor, and a personal companion. The CNA and the LPN did not make an attempt to cover the resident as the treatment was being administered.

In an interview with the CNA on August 18, 2011 at 11:40 AM, she stated the resident was totally exposed because the nurse had to treat the pressure ulcers on his buttocks. She said she had asked the personal companion to leave the room.

In an interview with the LPN on August 18, 2011 at 11:42 AM, she stated she spoke with the CNA after the resident's treatment and told her the resident should have been covered. She said she did not cover the resident as she was busy concentrating on the pressure ulcer treatment.

In summary, the resident was not provided with personal privacy during a medical treatment.

2) Resident #16 had diagnoses which included congestive heart failure and hypertension.

The Minimum Data Set assessment (MDS) dated February 9, 2011, documented the resident had short and long term memory impairment with moderately impaired cognition. This assessment documented the resident had pressure ulcers.

The physician order dated, June 2, 2011, documented to cleanse the pressure ulcer with normal saline and apply Santyl (an enzymatic ointment used to remove dead tissue) and cover with a Primapore dressing.

The surveyor observed the resident on August 17, 2011 from 9:40 AM to 10 AM, during the pressure ulcer dressing change. The pressure ulcer was measured by the registered nurse (RN) treatment nurse and was 3 cm x 4 cm x 4.1 cm (depth). The resident was lying on her side with her left buttock and thigh exposed. The door to the room was closed, there was no privacy curtain (private room). At 9:45 AM, there was a knock on the door. The RN said "come in", without covering the resident or knowing who was at the door. The licensed practical nurse (LPN) entered the room to assist with the dressing change. At 9:50 AM, there was a knock on the door. The RN said "yes", and the door was opened by a certified nurse aide (CNA). The CNA stood in the open doorway and spoke with the RN and the LPN, while the resident's left buttock and thigh were exposed.

The RN was not available for interview.

In summary, the resident was not provided with personal privacy during a medical treatment.

3) Resident #37 had diagnoses including seizure disorder, and anxiety.

The comprehensive care plan (CCP) updated on May 4, 2011, documented the resident was not independent with bed mobility, transfer, walking in room or corridor, locomotion on or off unit, dressing, toilet use, personal hygiene, or bathing. The CCP documented the resident received a bath/shower/complete bed bath one time per week.

The Minimum Data Set (MDS) assessment dated August 10, 2011, documented the resident had no cognitive impairment, was understood, and had no difficulty understanding others. The MDS assessment documented the resident required supervision or limited assistance with all activities of daily living (ADLs).

During the resident group interview held on August 17, 2011 at 10 AM, the resident stated the shower room door on the Valleycrest unit had a window with no curtain, and when he was in the shower room, anyone who walked by the door could see into the shower room. The resident stated sometimes staff would not close the shower curtain when he was being given a shower.

A surveyor observed the Valleycrest unit bathing room on August 17, 2011, between 1:30 PM and 2:30 PM. The door from the Valleycrest bathing room to the corridor had a vision panel (window) in the door.

In summary, the facility did not ensure the resident was given personal privacy during his shower, as the unit shower room door had an uncovered window, which allowed visibility by others from the corridor.

10NYCRR 415.3(d)(1)

Based on observation, resident and staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the nurse call system was operating properly in 2 of the 7 units where it was tested in Applewood and Valleycrest Units. Specifically, the nurse call system in the resident toilet rooms in 11 of 19 resident rooms tested in Applewood and Willoway Units was unreliable. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) During the environmental tour of Applewood Unit on August 16, 2011 between 2:45 PM and 3:45 PM, 10 resident rooms were sampled, which included testing the nurse call system. The nurse call system was not reliable in 4 of the 10 rooms sampled, rooms 750, 776, 779, 781. When the nurse call system was tested in resident toilet rooms by pulling the cord, the system did not turn on (generate a signal, including a light outside the resident room coming on) 6 out of 10 times the cord was pulled in rooms 750, 776, and 781, and 4 out of 10 times the cord was pulled in room 779.

An anonymous resident in one of the sampled rooms was interviewed on August 16, 2011 between 3 PM and 3:45 PM; he stated the nurse call system did not work in the toilet room.

When the Plant Operations Director was interviewed on August 16, 2011 between 2:45 PM and 3:45 PM, he stated he was not aware the nurse call system in this unit was not operating properly.

2) During the environmental tour of Willoway Unit on August 17, 2011 between 10:20 AM and 11 AM, 9 resident rooms were sampled, which included testing the nurse call system. The nurse call system was not reliable in 7 of the 9 rooms sampled, rooms 542, 548, 560, 563, 566, 578, and 583. When the nurse call system was tested in resident toilet rooms by pulling the cord, the system did not turn on (generate a signal, including a light outside the resident room coming on) 4 or 5 out of 10 times the cord was pulled in rooms 548, 560, 566, and 583, and did not turn on 2 or 3 of 10 times the cord was pulled in rooms 548, 563, and 578.

A preventative maintenance check of the nurse call system was documented on an undated log for the Martin Luther and Katherine Luther Buildings was being done monthly by staff in the Martin Luther and Katherine Luther Buildings.

In summary, the facility did not ensure the nurse call system was in reliable operating condition in 2 of 7 nursing units.

10NYCRR 415.29(b)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure activities were consistently provided in accordance with the assessment and comprehensive care plan for 3 of 11 residents reviewed for activities. This included Resident #25, and 2 residents outside the sample (Residents #35 and 36). Specifically, Resident #25's activity goals were not consistently met. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #25 had diagnoses of quadriplegia (paralysis of all extremities), dysphagia (difficulty swallowing), and tracheostomy (breathing tube in the neck).

The Therapeutic Recreation Annual Assessment, dated May 7, 2011, documented the resident was non-verbal and at times made eye contact. The activity interests included: Bible Reading, Hymn Sing, Prayer Visits, Hand Massage, TV, Radio, Pet Visits, Family/Friends Visits, Music Entertainment and Sing Along. The documented goals and plan of action were for more than 2 programs daily and also to offer one-to-one visits and activities. The special needs/activity restrictions assessment documented "no speech", and there were no other activity restrictions identified.

The resident's comprehensive care plan (CCP) updated May 17, 2011, documented: "Goal(s): resident's mental and psychological needs will be met by the individualized programs provided to him. He will attend programs as a passive participant for sensory simulation as conditions allows, and 1:1 visits, and pet therapy will be provided as available."
The approaches were listed as follows:
- staff will provide individualized programs such as reading to him, music, pet therapy, talking to him about the weather, news, etc.;
- staff will provide programs to resident's current functional status;
- bedside programming as indicated and tolerated;
- provide with a monthly calendar of daily programs, read to resident;
- utilize other disciplines to assure resident's needs are being met;
- staff will assist resident to programming, as needed;
- involve resident in small structured group activities as a passive participant for sensory stimulation; and,
- reevaluate in 90 days for adjustment in programming participation.

The physician orders, dated July 29, 2011, documented an order for activities as tolerated.

A physician progress note, dated July 29, 2011 documented the resident "opens eyes to verbal stimuli".

The Minimum Data Set (MDS) assessment, dated August 2, 2011 documented the resident was in a persistent vegetative state with no discernible consciousness, was totally dependent on staff to move in bed, transfer from the bed to a chair, and to move about on the unit.

On August 15, 2011 at 2:10 PM, the resident was observed in his private room, lying in bed with the lights off, the shades drawn and the room quiet.

The Therapeutic Recreation Quarterly Progress Note, dated August 16, 2011, documented the preferences for activities were in the residents's own room and on the unit. The activity preferences included music, pets, religious/spiritual, music and TV. Additional comments included "(the resident) at times will respond to pet visits and music."

On August 17, 2011 a 9:10 AM, the resident was observed in his room, lying in bed with the overbed light on and the room was quiet.

On August 17, 2011 at 9:15 AM, the registered nurse (RN) Unit Manager stated to the surveyor, "I didn't tell you he (the resident) was under 55 (years old) because I was thinking 'activities' and we don't do much of anything with him. He doesn't talk or interact, so he doesn't go to any activities, we put music on in his room or turn the TV on, but that's it. He does get up in his chair and we'll bring him out, but we wouldn't do any activities for someone like that."

On August 17, 2011, the resident was observed alone in his room at the following times:
- at 9:40 AM, lying in bed with the room quiet and the overbed light on;
- at 10:10 AM, lying in bed with the room quiet and the overbed light on;
- at 10:35 AM, lying in bed with the room quiet and the overbed light on;
- at 10:50 AM, up in a chair in his room with the television on; and,
- at 2:00 PM, lying in bed with the television on.

On August 17, 2011 at 10:15 AM, the activity aide was observed transporting other residents from the unit to "Hymn Sing", a scheduled activity.

On August 17, 2011 at 10:40 AM, the activity aide was asked by the surveyor how she knew which residents would enjoy being taken to "Hymn Sing". The activity aide stated, "everyone here loves the music activities, even if they can't speak."

On August 18, 2011 the resident was observed alone in his room at the following times:
- at 9:00 AM, lying in bed with the room quiet and the overbed light on;
- at 9:50 AM, lying in bed with the television on and the overbed light on; and,
- at 11:30 AM, lying in bed with the television on and the overbed light on.

On August 18, 2011 at 9:40 AM, the Activities Director was interviewed regarding the resident's participation in activities and stated, "we would take (the resident) to more activities, but he's always in bed." The activities director provided a 90 day log of the resident's activities to the surveyor, stated that all activities were documented on the log, and all one-to-one activities occurred in the resident's room.

A review of the resident's activity log dated May 23, 2011 through August 17, 2011, documented the resident received 18 one-to-one activity visits. The activities calendars for the resident's unit documented 265 scheduled activities during the same 90 day period that were identified on the resident's Therapeutic Recreation Annual assessment, as matching his activity interests. There was no documentation that the resident participated in any of those activities.

On August 18, 2011 at 10:05 AM, a licensed practical nurse (LPN) was interviewed and stated, "more could be done for him, he should be out of his room more. He needs more activities."

On August 18, 2011 at 11:10 AM, the social worker was interviewed and stated, "we do activities in his room for comfort." When asked to explain, she stated,"it's medical, we have to check with medical about bringing him out." The surveyor informed the social worker the resident had a physician's order for activities as tolerated and his equipment was portable. The social worker then stated, "well, we'll have to try harder then."

On August 19, 2011 at 9:45 AM, the resident was observed alone in his room, lying in bed with the overbed light on and the room quiet.

On August 19, 2011 at 9:48 AM, a surveyor interviewed a CNA (certified nurse assistant) who stated, "(the resident) has a gerichair, but we never really take him out of his room, I don't know why."

On August 19, 2011 at 10:00 AM, the physical therapist (PT) was interviewed and stated, "(the resident) has a gerichair that fits him. They keep it in the shower room on the unit and the nurses get him up to a recliner chair in his room. There's absolutely no reason why he can't leave his room and go to activities. We (the physical therapy department) bring this up at every care planning meeting, and there is no real explanation offered for not taking him to activities."

On August 19, 2011 at 10:20 AM, the activities aide was interviewed and stated, "I would love to take him out of his room to activities, I've taken him a few times to "Hymn Sing" and he really responds well to the music and just the stimulation of being out of his room. He has some equipment, but that all comes with him, it's really no problem. He's never up and out of bed in time for me to take him. He's always in bed."

The facility's policy titled Function of the Recreation Department, updated July 2009, was reviewed. The Recreation Department documented within their Philosophy of Recreation: it will be the responsibility of the Therapeutic Recreation Department to ensure that each resident within our care will be provided with extensive programming to meet the needs of all residents in accordance with the comprehensive assessment as well as the interests, physical, mental and psychological well-being of each resident. This mission is derived from the belief that each individual resident deserves the highest quality of life based on their individual interests.

In summary, the interdisciplinary team did not ensure:
- the resident was not isolated in his room;
- the resident was out of bed for scheduled activities;
- the resident was taken to activities of interest;
- activities and sensory stimulation were consistently provided in accordance with the resident's comprehensive care plan; and,
- the resident's activity goals and need for stimulation were consistently met.

2) Resident #35 had diagnoses including dementia, anxiety, and depressive disorder.

A quarterly Minimum Data Set (MDS) assessment dated May 26, 2011, documented the resident had severe cognitive impairment, was usually understood, and usually was able to understand others.

An Annual Therapeutic Recreation (TR) assessment, dated December 6, 2010, documented the resident enjoyed activities which included hymn sing, movies, musical entertainment, sing along's, religious services, and walking outdoors. Goals listed on the TR assessment included offering 1:1 visits/activities. It was documented the resident had no activity restrictions, and needed moderate/maximum encouragement to attend some activities. The TR assessment did not document special needs/social touch or sensory activities.

A TR quarterly progress note dated March 6, 2011, documented the resident was awake in the mornings and evenings, preferred morning and evening activities, and liked to participate in activities in her room, the activity room, on the unit, and off the unit at times. The TR progress note documented the resident's activity preferences were music, social programs, cognitive programs, movies/television, and physical programs. It was documented the resident continued to need encouragement from staff to attend activity programs, and left when she wanted to leave.

The comprehensive care plan (CCP) updated on June 9, 2011, documented the resident's mental and psychosocial needs would be met by the activities programing provided, and she would participate to her tolerance. Approaches documented on the CCP were: provide meaningful tasks/opportunities for success; bedside programing; evaluate needs, interests and abilities; and invite to programs to meet needs; offer/remind of special events/trips out; and assist to worship services as requested.

A TR quarterly progress note dated June 15, 2011, documented the resident was awake in the mornings and evenings, preferred morning and evening activities, and liked to participate in activities in her room, the activity room, on the unit, and off the unit at times. The TR progress note documented the resident's activity preferences were music, social programs, cognitive programs, movies/television, and physical programs. It was documented the resident was "a little slower getting around."

Physican orders dated June 30, 2011, documented the resident was on a regular diet with thin liquids, could have one beer every day as needed, and could participate in activities as tolerated.

The Individualized Daily Resident Care Card dated August 10, 2011, and used by the certified nurse aides to provide care, documented the resident was independent with ambulation, toileted herself, and was independent at meals after set-up assistance by staff.

During an interview with the resident's family member on August 18, 2011 at 12 PM, she stated the activities the resident was provided with were "always the same" and "very repetitious," with one example being a balloon toss activity. The resident's family member said said she visited the resident daily and said, "I observe a lot." She said the resident was not taken outdoors very often by staff, and the outdoor unit courtyard was not used for activities during nice weather. The resident's family member said the resident was rarely taken off the unit to attend activity programs, and needed to be re-approached if she refused. She said, "it is always the same crew (same residents) leaving to attend things off the unit." The resident's family member said the resident had never been approached by staff about attending Rosary or Happy Hour, which were activities held off the unit, and ones the resident would enjoy attending. The resident's family member said she did not feel there were enough activities, and especially tactile (sensory) activities, provided on the unit for residents with cognitive impairment. She said, "residents are bored and they are wandering into other residents' rooms."

When the Bryant unit activity calender was reviewed from May 1, 2011 through August 18, 2011, it was documented that 206 activities where held off the unit.

When the unit sign out logs (used when residents were taken off the unit to attend activity programs) were reviewed from May 1, 2011 through August 18, 2011, it was documented the resident attended one activity program off the unit (August 18, 2011), and no documented evidence the resident refused any activity programs.

The Director of Activities and the Bryant unit therapeutic recreation specialist (TRS) were interviewed jointly on August 19, 2011 at 8 AM. The TRS stated she did not schedule many activities outdoors, as she did not want residents sitting in the sun. The TRS said if a resident was taken into the unit courtyard, it was not documented in the unit sign out log. The Director of Activities stated it was not documented when a resident refused an invitation to attend a program off the Bryant unit. She also said all sensory activities on the Bryant unit were not documented on the activities calender. The Director of Activities said, "we fill in with things/activities as needed." When the TRS was asked by a surveyor about sensory activities provided to residents on the Bryant unit, she stated, I have not not done much of that." The TRS said she did more physical activities with the residents. The TRS said there use to be a sensory activity board/wall on the Bryant unit which was taken down, and they were trying to have it put back up. The TRS said the resident was not taken to Rosary because it was held off the unit. The Director of Activities said a pastor made individual visits to residents in their rooms, and Resident #35 could be added to the list. The TRS and the Director of Activities said the resident was not taken off the unit because she became anxious. The Director of Activities stated activities were combined for some units, and many of the joint activities were scheduled on the Gordon unit, because residents who reside on that unit told her they were uncomfortable coming to the dementia unit to attend activity programs.

In summary, the facility did not consistently provide for the resident, an ongoing program of activities designed to meet, in accordance with her care plan, activity preferences and interests, and her physical, mental, and psychosocial well-being.

3) Resident #36 had diagnoses including dementia and anxiety.

The initial therapeutic recreation (TR) assessment, dated April 5, 2011, documented the resident was able to choose activities of interest at times, and "loves to talk." The TR assessment documented the resident enjoyed talking/conversing, and one goal/plan of action was for the resident to be offered 1:1 visits/activities.

Physician orders, dated June 13, 2011, documented the resident could attend activities as tolerated.

The quarterly Minimum Data Set (MDS) assessment dated June 30, 2011, documented the resident had moderate cognitive impairment, was usually understood, and was usually able to understand others. The MDS assessment documented the resident required supervision from staff for all activities of daily living (ADLs).

A quarterly TR progress note, dated July 10, 2011, documented the resident was able to make her needs known, and was able to choose activities of interest. The TR progress note documented the resident preferred activities at all times of the day, and preferred activities in her own room, activity room, on and off the unit, and outside the facility. The resident's preferred activities were music, social programs, pets, cognitive programs, religious/spiritual, outdoor programs, physical programs and outings.

The comprehensive care plan (CCP) last reviewed by the interdisciplinary team on July 14, 2011, documented the resident was alert with confusion, and able at times to choose activities of interest. One goal listed on the CCP was the resident's mental and psychosocial needs would be met by the activities programming provided, and she would participate to tolerance. Approaches listed on the CCP included:
- the resident's needs interests and abilities would be evaluated, and she would be invited to programs to meet those needs;
- the resident would be offered programs to her match her current functional status, and her activity level would be increased as her physical or mental condition permitted and;
- the resident would be provided with meaningful tasks/opportunities for success.

On August 16, 2011 at 9:00 AM, the resident was observed standing at the unit nursing station, asking the ward clerk who was behind the desk, what she could do. The resident said, "there is nothing to do, what can I do?" The ward clerk told the resident there would be an activity program later that morning at 10:30 AM. The resident then went over to a chair nearby and sat down. Later that same day at 1:50 PM, the resident was observed seated in a chair near the unit nursing station for several minutes, and was overheard by a surveyor telling another resident who was seated next to her, there was nothing to do, and there was "nothing going on." There were no magazines, books, newspapers or other self-directed activity materials observed in the unit common area where the resident was seated. A surveyor observed several anonymous residents seated in chairs near the nursing station who were not engaged in any self-directed activity. Some of the residents were observed sleeping.

When the unit ward clerk was interviewed on August 16, 2011 at 9:15 AM, she stated there was not enough activities being offered on the Bryant unit, and that many activities were held on the Gordon unit. The ward clerk said there should be more activities going on for the residents.

During an interview on August 16, 2011 at 9:45 AM, the unit therapeutic recreation specialist (TRS) stated activities were combined for some units (Bryant, Saul and Gordon) and many were held on the Gordon unit. When a surveyor asked about scheduling more activities on the Bryant unit, the TRS said she could do more "balloon toss" with the residents.

On August 18, 2011 at 9:30 AM, the resident was observed seated in a chair near the unit nursing station. The resident was overheard by a surveyor as she spoke to another resident who was seated next to her, and told the other resident that it was "such a nice day, and I hope I can go outside today."

During a joint interview with the registered nurse (RN) Unit Manager, the Director of Activities, and the unit TRS on August 19, 2011 at 8 AM, the RN Unit Manager stated she thought there was one magazine for residents to look at on the unit. She said magazines seemed to disappear. The TRS told a surveyor she did not schedule many activities outdoors, as she did not want residents sitting in the sun.

In summary, the facility did not consistently provide for the resident, an ongoing program of activities designed to meet, in accordance with her care plan, expressed interests, and her physical, mental, and psychosocial well-being.

10NYCRR 415.5(f)(1)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 3 employees who initially failed the criminal background check was removed from a position of resident access in a timely manner, Employee #1. Specifically, Employee #1 was not removed from a position of resident access for over 2 weeks after the facility was notified the individual initially failed the criminal background check. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A job description in Employee #1's personnel file documented Employee #1 signed the job description in May 2011.

The undated Supervision Log for Temporary Employees documented the employee was a housekeeper. The supervision log documented the employee worked on August 2, 3, 4, 6, 7, 8, 9, 11, 12, 15, and 16, 2011.

A Pending Denial to Provider Letter dated August 1, 2011, documented Employee #1 was not eligible for employment in a position involving access to residents.

A Separation Notice dated August 16, 2011 documented Employee #1 was terminated.

When the Human Resources Director was interviewed on August 17, 2011, between 1:20 PM and 1:30 PM with another human resources (HR) staff present. She stated the HR staff directly responsible for reviewing the criminal background check (CHRC) results was on vacation when the facility was notified of the result. The Human Resources Director stated she had not realized Employee #1 had been hired; she stated Employee #1 was terminated when she became aware of the criminal background check results.

In summary, Employee #1 was not removed from a position of resident access in a timely manner after the facility received the criminal background check results.

NYCRR402.7(a)(2)(i)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure infection control standards were maintained for 1 resident (Resident #12) of 6 residents observed during a pressure ulcer dressing change. Specifically, staff left the pressure ulcers without a dressing for an undetermined amount of time, and staff did not cleanse the resident's 3 Stage II pressure ulcers before applying the dressing. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #12 had diagnoses including dementia and degenerative joint disease.

The CCP dated July 20, 2011, documented the resident was at moderate risk for skin breakdown, due to dementia and incontinence.

The resident's Minimum Data Set (MDS) assessment, dated August 11, 2011, documented the resident's cognition was severely impaired.

A physician order dated August 11, 2011, documented an order to cleanse the open areas on the right and left buttocks, apply RepliCare, and change the dressing every 3 days and PRN (as needed).

The Wound Measurement form, dated August 16, 2011, documented the resident had Stage II pressure ulcers as follows:
- the coccyx measurements were unchanged (from August 11, 2011) and the wound bed was 100% slough (dead tissue);
- the right buttock measured 4.0 cm x 2.7 cm with 100% yellow slough in the wound bed; and
- the left buttock measured 2.2 cm x 1.7 cm with 100% yellow slough in the wound bed. The treatment documented on this form for the 3 pressure ulcers was RepliCare every 5 days, and as needed.

The surveyor observed the resident's pressure ulcers on August 16, 2011 from 10:25 AM to 10:35 AM, during a dressing change. The resident was lying on the bed, and there was no dressing on the resident's buttocks or coccyx. The resident's buttocks were dusky red and excoriated. There were multiple open areas with 100% yellow slough; the coccyx pressure area was 100% green slough. The licensed practical nurse measured the areas, then applied 2 RepliCare dressings over the pressure ulcers. The LPN did not cleanse the pressure ulcer areas before applying the dressings.

In an interview with the LPN on August 19, 2011 at 10:45 AM, she stated the resident's pressure ulcers were without a dressing for an unknown amount of time. The LPN said the physician had been in that morning, and the dressing was removed so he could see the pressure ulcers. The resident then had a shower, and was assisted to bed afterwards to wait for the dressing to be applied. The LPN stated to the surveyor that she cleansed the pressure ulcers with wound cleanser before applying the RepliCare dressing.

In summary the facility did not ensure infection control standards were maintained during a pressure ulcer dressing change when:
- the pressure ulcers were left uncovered for an undetermined amount of time;
- staff did not cleanse the pressure ulcers per the physician order, before applying the RepliCare dressing.

10NYCRR 415.19(a)(1-3)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure the environment was free of accident hazards in 1 of 4 medical gas storage rooms observed (the Katherine Luther activities room closet) and that 1 of 11 residents reviewed for accidents (Resident #22) received the supervision necessary to prevent accidents. Specifically, a large tank (K tank) of compressed helium was stored in the activities room closet unsupported, and Resident #22 was not positioned at meals in a manner consistent with recommendations from the speech language pathologist. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE JUNE 24, 2010 SURVEY.

Findings include:

1) Resident #22 had diagnoses including dementia, depression, and dysphagia (difficulty swallowing).

The Minimum Data Set (MDS) assessment, dated May 26, 2011, documented the resident had severe cognitive impairment, sometimes was able to understand others, and rarely/never was understood. The MDS assessment documented the resident required total assistance from staff for all activities of daily living (ADLs), and was on a mechanically altered diet.

The most recent dysphagia evaluation completed by a speech language pathologist (SLP) on June 14, 2011, documented the resident continued to present with moderate oropharyngeal (throat) dysphagia due to the lack of dentition (teeth), resulting in decreased chewing skills, decreased coordination of swallow, and overt signs/symptoms of aspiration post thin liquid trials. The SLP recommended the resident continue to be fed by staff with pureed consistency solids and nectar thick liquids via a cup, and the resident was to be positioned upright. The dysphagia evaluation documented the registered nurse (RN) Unit Manager was notified of the results and recommendations of the evaluation.

The comprehensive care plan (CCP), updated on June 1, 2011, documented the resident used a reclining back wheelchair for locomotion, which was kept in a reclined position at 30-35 degrees, except for meals. The CCP documented the resident was out of bed for all meals, ate in the unit dining room, was fed by staff, and needed encouragement at meals. The CCP documented the resident had moderate oropharyngeal dysphagia related to the lack of dentition, and signs/symptoms of aspiration post thin liquid trials. The CCP documented the resident was to be monitored for coughing during fluid intake and she was not to use straws.

Physician orders, dated August 2, 2011, documented an order for a puree consistency diet with nectar thick liquids.

On August 16, 2011 at 12:35 PM, the resident was observed in the unit dining room at a table, reclined in her wheelchair at a 45-60 degree angle while she was being fed lunch by staff. A surveyor observed the resident coughing during the meal.

On August 17, 2011 at 8:20 AM, the resident was observed in the unit dining room at a table, reclined in her wheelchair at a 45-60 degree angle, while being fed breakfast by staff.

The resident was observed on August 18, 2011 at 8 AM, in the unit dining room at a table, reclined in her wheelchair at a 45-60 degree angle, and was being fed breakfast by a certified nurse aide (CNA). When interviewed at 8:02 AM, the same CNA said the resident was not seated in an upright position, and the back of her wheelchair could be adjusted to the upright position. The CNA said she did not feed the resident in an upright position because "she screams a lot." The CNA said she did not think it was comfortable for the resident to be seated upright, due to her contractures. The CNA told the surveyor upright meant the resident's wheelchair back would be positioned at 90 degrees.

When the occupational therapist (OT) was interviewed on August 18, 2011 at 8:10 AM, and after observing the resident being fed, she stated the resident probably should be positioned at 90 degrees in her wheelchair. The OT repositioned the resident's wheelchair to 90 degrees. The OT stated if it was uncomfortable for the resident to sit with the back of the wheelchair upright, there were positioning devices which could be used in the wheelchair to maintain the resident upright at 90 degrees, while being fed.

When the SLP was interviewed by telephone on August 18, 2011 at 8:40 AM, she stated upright meant the resident should be positioned at 90 degrees. The SLP stated it would be her expectation the resident was fed in an upright position, with her wheelchair being positioned at 90 degrees, or with the use of positioning devices.

In summary, the facility did not ensure the resident received the supervision necessary, when the resident was not fed in an upright position at meals per recommendation of the SLP.

2) When the Katherine Luther activities closet was observed on August 15, 2011 at 2:35 PM, there was a large, full tank (K tank) of helium that was unsupported (not restrained by a chain, or in a cart, etc.).

The Plant Operations Director was interviewed between 2:35 PM and 2:40 PM; he stated he was aware compressed gas tanks needed to be supported or restrained.

An activities department staff volunteered on August 15, 2011 at 2:37 PM that there was an error with the delivery, resulting in an extra helium tank in the activities room closet.

In summary, the facility did not ensure the environment was free of accident hazards due to the unsupported compressed gas tank.

10NYCRR 415.12(h)

Based on observation, resident and staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was palatable and served at the appropriate temperature on 1 of 3 nursing units observed, the Saul Unit. Specifically, the steam table on the Saul Unit did not maintain food hot enough during 2 meal observations, and residents at the resident group meeting raised concerns that hot food was not always hot when served. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

A surveyor observed the lunch meal service on the Saul Unit on August 16, 2011 between 12:45 PM and 1:15 PM. The hot food was in a heated steamtable with 4 wells (from the server's perspective, wells could be identified as left, left center, right center, and right). The right side of the steam table did not feel hot, and the water in the right steam table well was 147 degrees F. at 1:05 PM (immediately after the server finished serving). The heat control for the right well was set on 10, the highest heat setting.

Between 1:05 PM and 1:15 PM on August 16, 2011, the surveyor determined temperatures of multiple food items on the steam table:
- vegetable (Oregon blend) in the left center well was 130 degrees F..;
- baked potato in the right front well was 128 degrees F.;
- puree vegetable (Oregon blend) in the right well was 122 degrees F.;
- puree turkey in the right well was 122 degrees F.

A surveyor observed the lunch meal service on the Saul Unit a second time on August 18, 2011 between 12:50 PM and 1:15 PM. The surveyor determined temperatures of multiple food items on the steam table at 1 PM:
- puree potatoes were 118 degrees F. and did not taste hot;
- puree spinach was 123 degrees F. and did not taste hot;
- puree chicken was 132 degrees F. and tasted hot;
- whole spinach was 134 degrees F.

During the resident group meeting held on August 17, 2011 at 10 AM, 2 anonymous residents stated that hot food is sometimes served cold on the Saul unit.

The Food Service Director was interviewed on August 18, 2011 between 1 PM and 1:10 PM; she stated she was not aware of any issues with the steam table on Saul working properly.

The food service contractor's policy, titled Resident Services - Taste and Temperature Control, dated November 2009, documented before the start of each meal, "all equipment designed to maintain food at proper temperature is checked to be sure it is operational."

In summary, the facility did not ensure food was palatable and served at the appropriate temperature on one nursing unit.

10NYCRR 415.14(d)(2)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 27 current sampled residents (Resident #3), the facility did not ensure professional standards of quality were met. Specifically, for Resident #3, professional standards of quality were not met when a nasal spray was administered to the resident daily at 5 AM with no documented rationale. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #3 had diagnoses including Alzheimer's dementia, and osteoporosis.

Physician orders, dated June 29, 2011, documented the resident received 200 units of Fortical nasal spray (for the treatment of osteoporosis), one spray in one nostril, once daily (alternate nostrils).

The Minimum Data Set (MDS) assessment dated July 21, 2011, documented the resident had severe cognitive impairment, rarely/never was able to be understood, and sometimes was able to understand others. The MDS assessment documented the resident was totally dependent on staff for all activities of daily living (ADLs).

The medication administration record (MAR) for August 2011, documented the resident received 200 units of Fortical nasal spray every day at 5 AM. The August 2011 MAR did not document any other medications were scheduled for 5 AM.

The comprehensive care plan (CCP) last updated by the interdisciplinary team on August 4, 2011, documented the resident was non-ambulatory, and had a communication deficit, due to her difficulty in making herself understood, and in understanding others related to her dementia.

When interviewed on August 15, 2011 at 8:15 PM, the registered nurse (RN) Unit Manager said she had no idea why the resident was administered Fortical nasal spray daily at 5 AM, and had already changed the administration to 6 AM, when the resident was receiving other medications.

When the licensed practical nurse (LPN) medication nurse was interviewed on August 18, 2011 at 10:05 AM, she stated she did not understand why the resident was being administered the Fortical nasal spray at 5 AM. After the LPN med nurse reviewed the resident's medication administration record (MAR), she said the nasal spray should be administered at 6 AM when the resident received other medications, as there were no drug interactions that would have required the Fortical nasal spray to be given by itself. She said the resident was often resistive to being given her medications, so administering them later was better. The LPN medication nurse said nursing should have caught this, and changed the time.

In summary, the facility did ensure professional standards of quality were met when the resident was administered a medication at 5 AM, with no documented rationale.

10NYCRR 415.11(c)(3)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure food was stored under sanitary conditions in 1 of 7 nursing units, the Valleycrest Unit. Specifically, the under counter refrigerator in the Valleycrest kitchen was not operating properly during the survey and potentially hazardous foods in the refrigerator were not maintained at or below 45 degrees F. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

When the Valleycrest kitchen was observed on August 17, 2011 at 2 PM, there was a heavy ice buildup in the under-counter refrigerator and the air temperature in the refrigerator was 47 degrees F. At 2:14 PM, a surveyor determined the temperature of 3 milk products in the refrigerator:
- 1/2 gallon of Lactaid was 48 degrees F;
- 1/2 gallon of fat free milk was 50 degrees F; and
- 1/2 gallon of 2% milk was 49 degrees F.

After the Food Service Director and Production Manager came up to the unit at 2:14 PM, a surveyor rechecked food temperatures from this refrigerator:
- fat free milk was 51 degrees F;
- 2% milk was 51 degrees F;
- thickened milk from a 1 liter container was 51 degrees F; and
- a smoothie was 50 degrees F.

When the Food Service Director was interviewed on August 17, 2011 at 2:30 PM, she stated there were no problems reported related to the Valleycrest refrigerator temperature. When the Production Manager was interviewed on August 17, 2011 at 2:30 PM, she stated the refrigerator temperature was checked daily, early in the morning. The Food Service Director stated the food would be removed from the refrigerator and staff would call maintenance.

Preventative maintenance records (an untitled undated form) documented maintenance checked the Valleycrest under-counter refrigerator quarterly, specifically in February and June 2011. When the Plant Operations Director was interviewed on August 18, 2011 between 9 AM and 12 PM, he stated the under-counter refrigerators were defrosted quarterly.

In summary, the refrigerator was not operating properly to maintain potentially hazardous foods at, or below, 45 degrees F.

10NYCRR 415.14(h), 14-1.40(a)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 7 exits from the first floor of the Martin Luther building was free of impediments to full instant use in the case of emergency, the exit adjacent to the Martin Luther therapy room. Specifically, one of the two exit discharge doors of this exit was inoperable. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On August 17, 2011 between 9:30 AM and 10 AM, a surveyor tested an exit in the Martin Luther building next to the therapy room. The exit had a set of double doors to the outside (2 exit discharge doors). One of the two exit discharge doors, the door on the right side when exiting the building, would not open after multiple attempts to open it.

When the Plant Operations Director was interviewed on August 17, 2011 between 9:30 AM and 10 AM, he stated he was not aware the door was inoperable, and there was currently no preventative maintenance program to ensure exit doors remained operable. He stated this exit was only an emergency exit, thus this exit was not used by staff to enter or leave the building.

In summary, the facility did not ensure the exit was free of impediments to full instant use in an emergency, as required.

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