James Square Health and Rehabilitation Centre

Based on observation, staff interview, and record reviews conducted during the standard survey, it was determined the facility did not ensure sanitary conditions were maintained during food preparation and storage as refrigeration was not working properly and potentially hazardous food was not maintained at or, below, 45 degrees F. for 3 of 23 refrigerators (main kitchen Holding Refrigerator, main kitchen Roll-in Refrigerator #1, and B South's nourishment refrigerator). Refrigerator thermometers were not accurate and did not operate properly in 3 of 23 refrigerators (kitchen milk cooler; Fourth Floor and D Floor nourishment refrigerators; and 2 potentially hazardous foods were not refrigerated while held for service (TwoCal HN supplement and milk). The facility also did not ensure dishware (mugs, bowls, and plates) was consistently clean; and multiple surfaces were not maintained in clean condition in the kitchen. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) POTENTIALLY HAZARDOUS FOODS NOT REFRIGERATED PROPERLY:
a) The "Policy and Procedure for Recording Refrigerator and Freezer Temperatures", dated July 19, 1999, documented Nutrition Services (Dietary) Supervisors were to check refrigerator temperatures twice daily; return to a refrigerator in one hour to recheck the refrigerator temperature if abnormal; and check the temperature of perishable foods if the refrigerator temperature was greater than 45 degrees (F.).

On July 18, 2011 between 6:20 PM and 6:45 PM, the Dietary Supervisor told the surveyor that the Holding Refrigerator (walk-in refrigerator used for trayline service) had not been working properly and was being repaired. Roll-in Refrigerator #1 was adjacent/connected to the Holding Refrigerator.

Review of the "Closing Cooler/Freezer Temperature Logs" for July 2011 revealed the Roll-in Refrigerator #1's air temperature was 50 degrees F. on July 11, 2011; was 60 degrees F. on July 13, 2011; was 45 degrees F. on July 15, 2011; and was not recorded on July 17, 2011.

The surveyor interviewed the Manager of Nutritional Services on July 20, 2011 on 2:20 PM regarding the temperature logs for Roll-In Refrigerator #1 and the documented elevated temperature readings. The Manager stated she documented in the log that the temperature of Roll-In Refrigerator #1 on July 8, 2011 was 50 degrees F. She stated she was aware the temperature was out of compliance and said she found the door slightly open at that time. She stated she discarded the rack of food, closed the door, and waited 15 minutes. The Manager said when she re-took the temperature, it must have been in the acceptable range, or she would have contacted Maintenance. There was no documentation of the second temperature taken by the Manager on that date.

A surveyor observed Roll-in Refrigerator #1 on July 18, 2011 at 7:10 PM. The refrigerator's air temperature was 55 degrees F. per refrigerator thermometer. Between 7:10 PM and 7:20 PM, the surveyor determined food temperatures from this refrigerator to be:
- puree beef was 62 degrees F.;
- brown gravy was 61 degrees F;
- chicken gravy was 61 degrees F.

The surveyor interviewed a Dietary Supervisor and the Food Service Director between 7 PM and 7:20 PM on July 18, 2011. They stated the facility planned to discard the food on the cart in the left side of the cooler. They said the food on the cart in the right side of the cooler was being saved for nursing units who called for additional food.

When the surveyor interviewed the Food Service Director on July 18, 2011 between 7:30 PM and 7:45 PM, the Director stated the food in Roll-in Refrigerator #1 would be discarded.

When the Food Service Director was re-interviewed on July 20, 2011 at 4:10 PM, she stated the Roll-in Refrigerators were operated by some of the same refrigeration equipment as the Holding Refrigerator. She stated she was not notified Roll-in Refrigerator #1's temperature had been running too high.

In summary, the facility did not ensure this refrigerator was operating properly and maintained potentially hazardous foods at or below 45 degrees F., as required.

b) The surveyor interviewed a Dietary Supervisor on July 19, 2011 between 5:35 PM and 5:45 PM. She stated there was more food than normal in the Holding Refrigerator, as the Assembly Room Refrigerator was still being repaired. The Holding Refrigerator was a large walk-in refrigerator used to hold all residents' meal trays, before reheating prior to serving the meal.

On July 19, 2011 at 5:30 PM, a surveyor observed the air temperature in the Holding Refrigerator to be greater than 52 degrees F. At 5:35 PM, gravy in a 4 inch deep container was 55 degrees F in this refrigerator.

At 5:50 PM on July 19, 2011, the Holding Refrigerator contained more than 10 carts of residents' meal trays. Food temperatures from these residents' meal trays in this Holding Refrigerator were determined to be:
- chicken noodle soup was 55 degrees F.;
- cottage cheese was 56 degrees F.;
- (unlabeled) puree meat was 56 degrees F.

The Food Service Director was present during the July 19, 2011 5:50 PM observation and she notified Maintenance staff that the Holding Refrigerator was not operating properly.

At 6 PM on July 19, 2011, the surveyor checked the air temperature of the air blowing into the Holding Refrigerator directly in front of the fan; the air temperature was 54 degrees F. The Food Service Director was immediately advised the temperature of the air coming into the refrigerator was too high.

When the Vice President for Support Services was interviewed on July 19, 2011 at 6:40 PM, he stated the Holding Refrigerator contain the breakfast and lunch meals for all the residents for the following day. He stated the facility decided to move the breakfast trays to another refrigerator and discard the lunch trays. He stated a new lunch meal would be prepared the following day. There was no rationale for not discarding the breakfast meal trays.

At 6:45 PM on July 19, 2011, the surveyor checked the temperature of the air blowing into the Holding Refrigerator; the air temperature remained 54 degrees F.

Review of the Closing Cooler/Freezer Temperature Logs for July 2011 revealed the Holding Refrigerator air temperature were documented to be:
- 46 degrees F. on July 10, 2011;
- 50 degrees F. on July 11, 2011;
- 49 degrees F. on July 12, 2011;
- 45 degrees F. on July 13, 2011;
- 46 degrees F. on July 14, 2011;
- 49 degrees F. on July 15, 16, and 17, 2011;
- 50 degrees F. on July 18, 2011.

When the surveyor interviewed the Director of Food Service was interviewed on July 20, 2011 at 1:15 PM, she said reviewed the temperature logs either on a weekly or monthly basis. She said the dietary supervisors were responsible for completing the temperature logs on a day to day basis.

A Dietary Supervisor was interviewed on July 20, 2011 at 12 PM. She stated she was not aware of a problem with the Holding Refrigerator.

The Vice President for Support Services was interviewed on July 20, 2011 at 12:20 PM regarding a refrigerator not working properly. He was not sure if maintenance was notified multiple times when the Holding Refrigerator was not operating properly.

On July 20, 2011 at 2:15 PM, the surveyor interviewed the dietary Production Coordinator who stated she sometimes took temperatures when she filled in for the dietary supervisors. The Production Coordinator said that on July 5, 2011, she documented the temperature in the Holding Cooler was 46 degrees. She said dietary staff were in and out of the refrigerator, and she would watch the temperatures. The Production Coordinator was aware the temperature in the Holding Cooler was out of compliance. She said she did not know if she notified maintenance on July 5, 2011.

A Dietary Supervisor was interviewed on July 20, 2011 at 4 PM and stated she checked the refrigerator temperatures around 7:30 PM when she was on duty. She stated she did not follow up high refrigerator temperatures by checking the food temperatures.

In summary, the facility:
- did not ensure the Holding Refrigerator was operating properly;
- did not ensure potentially hazardous foods were maintained at, or below, 45 degrees F., as required;
- did not ensure staff followed the policy for addressing problems with refrigerator temperatures.

c) During environmental rounds on the 2 South Unit on July 22, 2011 at 10:30 PM, the surveyor observed an open can of TwoCal HN nutritional supplement on top of an unattended medication cart at the nursing station.

On July 22, 2011 at 11:30, the open can of TwoCal HN remained on the medication cart at the 2 South nursing station, and remained unattended. A surveyor determined the temperature of the supplement was 72 degrees F.

When the registered nurse (RN) Unit Manager was interviewed on July 22, 2011 at 11:30 AM, she stated she believed it was acceptable practice to have the open can of unrefrigerated supplement on the medication cart. When the licensed practical nurse (LPN) medication nurse was interviewed on July 22, 2011 at 11:35 AM, she stated the supplement was on the medication cart from the 8 AM medication pass. She said she left the supplement from the 8 AM pass until the 12 PM medication pass, and she had been told not to leave the supplement out on the medication cart.

During environmental rounds on the D Floor on July 21, 2011 between 9:30 AM and 10:30 AM, a surveyor observed a 1/2 gallon container of milk was left on the counter in the D Floor serving kitchen. The kitchen was unoccupied and the milk temperature was determined to be 63 degrees F. Staff discarded the milk after the observation.

In summary, the liquid nutritional supplement and milk were not refrigerated while being held for service.

d) The surveyor observed B South's nourishment refrigerator on July 21, 2011 between 1:37 PM and 2:20 PM. The air temperature was above 50 degrees F. per refrigerator thermometer. Food temperatures determined by a surveyor included:
- 2% milk from an 8 ounce container was 47 degrees F.;
- whole milk from an 8 ounce container was 51 degrees F; and
- nectar consistency thickened water was 48 degrees F.

The Vice President for Support Services was present during the July 21, 2011 observation between 1:37 PM and 2:20 PM and stated the food in the refrigerator would be discarded.

Review of "The Closing Day Room Refrigerators temperature log" for July 2011 revealed B South nourishment refrigerator's temperature was documented to be 50 degrees F. on July 13 and 14, 2011; 52 degrees F. on July 19, 2011; and 49 degrees F. on July 21, 2011.

An undated invoice from a contract company documented the Holding Refrigerator was assessed June 28, 2011 and determined a new part (evaporator coil) was needed. A proposal from the same contractor, dated July 11, 2011, documented a price estimate to repair the Holding Refrigerator, and replacing the evaporator coil. The repair was not initiated prior to survey.

In summary, the facility did not ensure this refrigerator was operating properly and maintained potentially hazardous foods at or below 45 degrees F., as required.

2) INACCURATE REFRIGERATOR THERMOMETERS:
On July 18, 2011 between 6:30 PM and 6:45 PM, the surveyor observed the kitchen's milk refrigerator thermometer was no longer operable due to multiple separations (air bubbles) between the red liquid in the thermometer.

On July 19, 2011 at 10:15 AM, a surveyor observed the thermometer in the fourth floor nourishment refrigerator to no longer be operable due to multiple air bubbles between the red liquid in the thermometer.

On July 21, 2011 between 9:30 AM and 10:30 AM, a surveyor observed the thermometer in the D Floor nourishment refrigerator to no longer be operable due to multiple air bubbles between the red liquid in the thermometer.

The surveyor interviewed a Dietary Supervisor on July 21, 2011 at 9:45 AM who stated she did not know when the red liquid in a thermometer separated, that the thermometer was not longer operable.

In summary, the facility did not ensure refrigerator thermometers were accurate.

3) DISHWARE NOT CONSISTENTLY CLEAN:
A surveyor checked dishware for cleanliness in the B Unit dining room on July 21, 2011 between 11:30 AM and 11:40 AM. Observations included:
- 5 plastic coffee mugs were stained with a brown film;
- 2 plastic soup bowls were stained with a film;
- 2 china plates had food debris remaining on them.

The surveyor interviewed the dietary server on July 21, 2011 at 11:40 AM. She stated staff would not use the soiled dishes to served food; these items would be returned to the kitchen.

The Food Service Director was interviewed on July 21, 2011 at 5:30 PM and stated the facility manually removed stains from the plastic mugs and bowls, not on a regular/routine frequency.

In summary, dishware was not consistently cleaned thoroughly by the facility's cleaning process.

4) SOILED SURFACES:
a) A surveyor observed multiple floor surfaces in the kitchen were soiled on July 18, 2011 between 6:30 PM and 6:45 PM, including:
- the floor behind the steamer was soiled with debris;
- the floor in the small dry storage room was littered with multiple portion control (PCs) containers, 4 containers of Jello, multiple PCs of condiments and paper debris;
- the paper products storage room floor was littered with multiple plastic spoons and forks;
- the floor behind the dishwasher was soiled with debris and it remained soiled when observed the following day on July 19, 2011 at 5:20 PM.

b) A surveyor observed the fan in the kitchen pot washing room was heavily soiled on July 18, 2011 between 6:30 PM and 6:45 PM and when observed on July 19, 2011 at 1:20 PM.

The Food Service Director was interviewed on July 21, 2011 at 5:30 PM. Her written response provided to the surveyor on July 22, 2011 documented the floor in the dishroom, dry storage room, and paper products room were scheduled for daily cleaning.

The undated PM Supervisor Check List documented the evening supervisor was scheduled to check that cleaning was completed in the storage rooms and dishroom.

In summary, multiple surfaces in the kitchen were not consistently maintained in clean condition.

10NYCRR 415.14(h), 14-1.40(a), 14-1.85, 14-1.170 and 1.71

Based on observation, resident and staff interview, and record reviews conducted during the standard survey, it was determined the facility did not ensure foods served were palatable and at the proper temperature for 2 of 2 resident units (A South Unit and 1 South Unit, including Residents #31- #43) sampled for HS (evening) snacks, as their milk and ice cream snacks were not served at a palatable temperature. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

On July 18, 2011 at 6:50 PM, the surveyor observed staff passing nourishments for 11 residents (Residents #31-#41) from a tray at the nursing station on A South Unit. These nourishments included milk, milk shakes, cottage cheese, and yogurt.

At 7 PM on July 18, 2011, the surveyor requested Dietary Supervisor #1 to take the temperature of an 8 ounce container of milk for Resident #35 and a 4 ounce container of milk for Resident #36. The 8 ounce milk was 60 degrees F, and the 4 ounce milk was 59 degrees F.

The surveyor interviewed Dietary Supervisor #1 on July 18, 2011 at 7 PM. She stated she was not sure what happened to residents' nourishments after dietary delivered them to the unit.

On July 18, 2011 at 7:10 PM, they surveyor interviewed the certified nurse aide (CNA #3) who was currently passing nourishments. She stated she found the nourishments on the nursing desk after she finished assisting the residents.

On July 18, 2011 at 7:15 PM on 1 South Unit, the surveyor observed CNA #4 passing nourishments from a tray at the nursing station, including a container of melted ice cream for Resident #42 and, a container of milk for Resident #43. The temperature of the milk was 60 degrees F.

The surveyor interviewed CNA #4 on July 18, 2011 at 7:15 PM. She stated the tray of nourishments came out of the unit refrigerator. She did not know who brought the tray out and put it at the nursing station, or when it was put there.

In a surveyor interview with Dietary Supervisor #2 on July 18, 2011 at 7:20 PM, she stated dietary brought the nourishments to the units at 6:45 PM, and put them in the unit refrigerator.

On July 19, 2011 at 10 AM on 2 South Unit, the surveyor observed a dietary aide bring 2 trays of nourishments to the unit. The surveyor overheard the dietary aide tell a nursing staff member that she did not know where to put the tray of nourishments, as she left the tray at the nursing station.

During the resident group meeting with the surveyor on July 20, 2011 at 10:30 AM, 5 of 14 anonymous residents in attendance, expressed concerns about HS snacks. These concerns included warm cottage cheese, warm milk, warm milk shakes, warm Jello, warm "drippy" yogurt, and melted sherbet. One of the 5 anonymous residents stated they could "drink" the Jello; another anonymous resident stated the nourishment tray was left out "many hours" at the nursing station.

The surveyor interviewed the Food Service Director on July 21, 2011 between 5:30 PM and 6 PM. She stated the procedure at this facility was for dietary staff to deliver nourishments to the nursing units and place them in the refrigerators. She provided a written note, dated July 22, 2011, that specified it normally took 10 to 15 minutes to deliver the nourishments from the kitchen to the nursing units.

In summary, sampled HS snacks were not served to the residents at palatable temperatures on 2 of 2 nursing units, affecting at least 13 residents on those units.

10NYCRR 415.14(d)(2)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure staff maintained effective infection control program for 1 of 5 residents (Resident #11) observed during a dressing change. Specifically, staff did not perform hand hygiene during Resident #11's dressing change; and staff lifted a urinary catheter bag above the height of Resident #11's bladder during this dressing change. This resulted in no actual harm, with the potential for more than minimal harm that is not immediate jeopardy.

THIS IS A REPEAT DEFICIENCY FROM THE JUNE 11, 2010 SURVEY.

Findings include:

Resident #11 had the diagnoses of COPD (chronic obstructive pulmonary disease), depression, and pressure ulcers.

The Minimum Data Set (MDS) assessment, dated May 31, 2011, documented the resident was cognitively intact and had an indwelling catheter.

The physician orders dated June 29, 2011, documented the resident was to have:
- a urinary catheter in place for healing a Stage III coccyx wound;
- to the right pelvis wound, staff were to apply Collagenase (ointment); cover with 2 x 2 gauze and Tegaderm (dressing); and to change it everyday;
- to the coccyx wound, staff were to apply Collagenase, cover with 2 x 2 gauze and Tegaderm; and be changed everyday;
- to the left hip wound, staff were to apply Collagenase, cover with 2 x 2 gauze and Tegaderm; and be changed everyday.

The surveyor observed the resident's dressing change on July 21, 2011 from 9:45 AM to 10:08 AM. The registered nurse (RN) Unit Manager and a certified nurse assistant (CNA) were present when the:
- the RN assembled wound care supplies, including a trash can at the right side of the resident's bed.
- the CNA stood at the left side of the resident's bed, to assist with positioning the resident.
- the RN completed the dressing change on the exposed side of the resident. The RN removed her gloves and switched positions with the CNA.
- the CNA lifted the garbage can over the bed and handed it to the RN, who used her bare hands and placed it on the floor.
- the RN lifted the resident's urinary catheter bag with her bare hands from the side of the bed, lifted it above the height of the resident's bladder and, handed it to the CNA to place on the opposite side of the bed. Urine was observed in the catheter tubing.
- the RN donned clean gloves without performing hand hygiene and completed the dressing change on the exposed side of the resident.
- the CNA lifted the urinary catheter bag above the height of the resident's bladder and handed it to the RN to place on the other side of the bed.

On July 21, 2011 at 10:10 AM, the surveyor interviewed the RN who offered no explanation for not performing proper hand hygiene, after handling the garbage can and the resident's urinary catheter bag. The RN stated "Oh" when asked about the urinary catheter bag with urine in the tubing, that was lifted twice above the height of the resident's bladder.

On July 21, 2011 at 10:20 AM, the CNA was interviewed and stated, "the level of the catheter drainage bag should always be level with the bladder."

On July 22, 2011 at 12:50 PM the RN Infection Control nurse was interviewed and stated, "She (the RN) should have definitely washed her hands (after handling the trash can)." She also stated the catheter drainage bag should not be higher than the bladder.

In summary, the facility did not ensure an effective infection control program was maintained, when:
- staff did not perform proper hand hygiene during a dressing change;
- when staff lifted the urinary catheter drainage bag above the level of the resident's bladder.

10NYCRR 415.19

Based on observation, record review, and staff interview conducted during the standard survey, it was determined for 1 of 9 residents (Resident #5) reviewed for accidents, the facility did not ensure the environment was free from accident hazards. Specifically, Resident #5 was not fed all meals in her gerilounge chair, as recommended by occupational therapy (OT). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #5 had diagnoses including advanced Alzheimer's disease.

The quarterly Minimum Data Set (MDS) assessment, dated May 19, 2011, documented the resident had severe cognitive impairment, and was totally dependent on staff for all activities of daily living (ADLs).

The comprehensive care plan (CCP), dated May 20, 2011, documented the resident needed a therapeutic diet, and had impaired chewing abilities. The documented goals were that the resident would be free of choking, and would receive a swallowing evaluation as needed.

Physician orders, dated June 1, 2011, specified the resident received a high protein, pureed consistency diet, with thin consistency liquids.

The undated certified nurse aide (CNA) Plan of Care, in use during the survey, documented the resident needed to be fed and was in bed for breakfast.

An OT progress note, dated June 22, 2011, documented nursing questioned whether the resident should continue to be fed in her gerilounge chair, or fed in bed. The OT note documented the resident should continue to be fed meals in her gerilounge chair, with the back of the chair upright at a 90 degree angle.

The surveyor observed the resident on July 21, 2011 at 8:45 AM being fed her breakfast in bed, by CNA #1. The surveyor interviewed CNA #1 at that time. CNA #1 stated she always fed the resident breakfast in bed, and thought the resident was up for lunch and supper.

On July 22, 2011 at 8:15 AM, the resident was observed in her room in bed, being fed her breakfast by CNA #2. When the surveyor then interviewed CNA #2, she said the resident always ate breakfast in bed, and was not sure if she was up for lunch or supper.

The surveyor interviewed the OT on July 22, 2011 at 9:55 AM. The OT stated the resident should be fed all meals in her gerilounge chair. The OT said the resident was more comfortable in the gerilounge chair, and received better neck support. The OT stated the resident should be up and out of bed, as much as possible and said this recommendation was communicated to nursing staff through the OT progress note.

When the surveyor interviewed the registered nurse (RN) Unit Manager on July 22, 2011 at 10:25 AM, the Unit Manager stated she was unaware of the resident's OT evaluation on June 22, 2011 for feeding recommendations. The RN said she thought it was for positioning only.

In summary, the facility did not ensure the environment was free from accident hazards, when the resident was fed breakfast in bed in conflict with OT's recommendation to feed the resident all her meals in her gerilounge chair.

10NYCRR 415.12(h)(1)

Based on observations, resident and staff interviews, and record reviews conducted during the standard survey, it determined the facility did not ensure the environment was clean, comfortable, and homelike for 2 of 27 current residents in the survey sample. Specifically, a bare bedframe was left in Resident #20's room; and Resident #5's "serenity pad" (full length, fabric cushion used for comfort) used in her geri lounge chair, was soiled, stained, and not laundered in a timely manner. This resulted in no actual harm, with the potential for more than minimal harm, that is not immediate jeopardy.
Findings include:

1) Resident #20 had diagnoses of dementia, hypertension, and mental retardation.

The Minimum Data Set (MDS) assessment, dated May 29, 2011, documented the resident had short term memory problems and had severely impaired cognition.

On July 18, 2011 at 6:40 PM, the surveyor observed the resident in her semiprivate room; seated on her bed, closest to the window. The room's second bed (closest to the door) was bare and had no mattress, with the frame and springs visible. The resident appeared to be talking to herself and when asked about the bare bed stated it had been like that, "for awhile". The resident did not provide further information.

The surveyor observed the resident in her room on July 19, 2011 at 1:10 PM, on July 20, 2011 at 11:00 AM, and on July 21, 2011 at 9:10 AM and at 11:00 AM. On those 4 occasions, the bed closest to the door was bare, and had no mattress; the surveyor observed the bed frame and springs to be exposed.

At 3:15 PM on July 21, 2011, the surveyor interviewed the licensed practical nurse (LPN) charge nurse regarding the resident's room. The LPN stated the resident's mattress needed to be replaced, so staff took the mattress from the bed closest to the door. The LPN charge nurse stated this occurred "about 2 weeks ago". When the surveyor asked the LPN if she felt the resident's room was clean, comfortable, and homelike, the LPN stated, "no."

On July 21, 2011 at 3:20 PM, the surveyor interviewed the registered nurse (RN) Unit Manager regarding the resident's room. The RN stated, "we took the mattress off 2 weeks ago and swapped them out" with the mattress from the bed by the door. The RN stated, "no" when the surveyor asked if she felt the resident's room was clean, comfortable and homelike.

The surveyor observed the resident on July 22, 2011 at 9:05 AM to be standing beside her bed, talking to herself. The bed closest to the door was bare with no mattress, and the bed frame and springs remained exposed.

On July 22, 2011 at 11:10 AM, the surveyor interviewed the Director of Housekeeping who stated, "I wasn't aware the mattress wasn't on the bed; all nursing has to do is send a requisition to Central Supply and it can be replaced right away. It (the bed frame) shouldn't be left bare, it should be made up. I'll see that it is taken care of right away." When asked if she felt the bare bed made the resident's room clean, comfortable and homelike, she stated, "most definitely not."

On July 22, 2011 at 11:40 AM, the social worker was interviewed regarding the resident's room. She stated the resident did not always let housekeeping into her room, "so, we don't want to have the other bed get messed up by (the resident)." The social worker was then asked if she felt the resident's room was clean, comfortable and homelike with the bare bed frame and springs. The social worker stated, "yes, she (the resident) has a family picture on her side of the room."

In summary, the facility did not ensure the resident's room was clean, comfortable, and homelike when a bed in her room was left bare for at least 2 weeks, with the bed frame and springs left exposed.

2) Resident #5 had a diagnosis of advanced Alzheimer's disease.

The quarterly Minimum Data Set (MDS) assessment, dated May 19, 2011, documented the resident had severe cognitive impairment, rarely/never understood others, and was rarely/never able to be understood. The MDS assessment documented the resident was totally dependent on staff for all activities of daily living (ADLs).

The resident's comprehensive care plan (CCP) dated May 3, 2011, physician's orders dated June 1, 2011, and the undated certified nurse aide (CNA) Plan of Care used during survey, documented the resident used a geri lounger chair with a Roho cushion and a serenity pillow for positioning and comfort.

On July 18, 2011 at 6:40 PM, the surveyor observed the resident seated in her geri lounge chair in the unit corridor outside of her room. The resident was sitting on the serenity pillow that was very soiled, with multiple, dark brown stains along both sides, and at the bottom of the pillow.

On July 20, 2011 at both 10 AM and 3:30 PM, the surveyor observed the resident lying in bed. The resident's geri lounge chair, located near her bed, was observed to have a serenity pillow which was very soiled, with multiple, dark brown stains along both sides, and at the bottom of the pillow.

On July 21, 2011 at 8 AM, when the surveyor observed the resident in bed, her serenity pillow her geri lounge chair was touching the floor and remained soiled and stained.

The surveyor interviewed the occupational therapist (OT) on July 22, 2011 at 9:55 AM. After the OT observed the resident's serenity pillow, she stated it needed to be laundered. The OT said there were extra pads available, and the soiled pad should have been replaced while it was being laundered.

When the surveyor interviewed the resident's primary CNA (certified nurse aide) on July 22, 2011 at 10:15 AM, the CNA observed the soiled serenity pillow and said it needed to be washed. The CNA stated the pillow looked like it had not been washed "in a while." The CNA did not know if the resident had another pad to use while the soiled one was being washed.

The Director of Nursing (DON) was interviewed on July 22, 2011 at 1:40 PM, and said there was no policy for cleaning residents' support/positioning equipment. The DON stated the facility had enough stock, so when equipment became soiled, it could be replaced and washed. The DON said staff were instructed to do this.

In summary, the facility did not provide a clean, comfortable and homelike environment for the resident, as her stained and soiled serenity pillow was not laundered in a timely manner.

10NYCRR 415.5(h)(1)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure required monthly generator tests under load were done for 2 of 2 emergency generators (in both their 906 and 918 Buildings), and did not ensure 1 of 2 emergency generators (in the 918 Building) was maintained in reliable operating condition. Specifically, the last documented load test was conducted in September 2010 on 1 of the emergency generators in their 918 Building; and the facility did not conduct 3 monthly load tests as required for the emergency generator in their 906 Building. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) The undated 918 Building Generator Log documented emergency generator load tests were not done for the 918 Building's emergency generator since September 2010.

The surveyor interviewed the Maintenance Co-Director on July 22, 2011 between 9 AM and 11 AM. He stated the facility was concerned the the 918 Building's emergency generator transfer switch was not in good condition. The Co-Director stated the facility did not want to risk a problem with that generator, so the load tests were not being done. He stated repair of this generator was complicated, and one contractor refused to attempt to repair it.

A review of a contract company's proposal, dated May 9, 2011, revealed a proposal to repair the 918 Building emergency generator, including replacing the transfer switch.

In summary, the facility did not ensure the 918 Building emergency generator was repaired in a timely manner, in order for it to be in reliable operating condition and the required monthly load tests could be done.

2) The undated 906 Building Generator Log documented emergency generator load tests for that building's emergency generator were not documented to be conducted in August 2010, December 2010, and April 2010, as required.

In summary, monthly loads tests for the 906 Building emergency generator were not done for 3 of the last 12 months.

10NYCRR 415.29(a)(1&2), 711.2(a)(20)