Valley View Manor Nursing Home

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure potentially hazardous food (pork roasts) were cooled in a timely manner, in accordance with state regulations. Specifically, pork roasts were not cooled in a manner that allowed cooling from 120 degrees to 70 degrees F. in 2 hours or less. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The facility menu, dated April 10, 2011, documented the main entree for the lunch meal on Wednesday Week 2 (May 4, 2011) was an open face pork sandwich.

The surveyor observed 4 boneless pork roasts cooling in the walk-in refrigerator on May 3, 2011 at 10:25 AM. These roasts were packed close together in a pan and tightly covered with plastic wrap. The 4 pork roasts remained as above when observed that same day at 10:55 AM, at 12:35 PM, and at 1:05 PM.

On May 3, 2011, the surveyor determined the temperature of the pork roasts to be:
- at 10:58 AM: Roast #1 = 143 degrees F; Roast #2 = 143 degrees F; Roast #3 =139 degrees F; and Roast #4 =151 degrees F.
- at 12:35 PM: Roast #1 = 94 degrees F; Roast #2 = 106 degrees F; Roast #3 = 107 degrees F; Roast #4 = 113 degrees F.
- at 1:05 PM: Roast #1 = 91 degrees F; Roast #2 = 97 degrees F; Roast #4 = 102 degrees F; (temperature of Roast #3 not taken).

When the cook was interviewed on May 3, 2011 between 12:45 and 1 PM, he told the surveyor he normally cut roasts into pieces 4 pounds, or less, to facilitate cooling.

When the surveyor advised the Food Service Director that the pork roasts were not cooling in a timely manner on May 3, 2011 at 1:10 PM, she changed the cooling process to allow them to cool more timely.

In summary, potentially hazardous foods were not cooled in a timely manner as required.

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

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not ensure a ongoing activity program was implemented to meet the physical, mental, and psychosocial well-being for 2 ( Residents #7 and 10) of 13 residents reviewed for activities. Specifically, the facility did not did not ensure Resident #10 had a current activity assessment that addressed her mental and psychosocial needs; did not ensure the certified nurse aide (CNA) direct plan of care specified the resident's activity needs; did not ensure activities and sensory stimulation were consistently provided in accordance with Resident #10's care plan; and did not ensure Resident #10's activity goals were consistently met. For Resident #7, the facility did not ensure activities and sensory stimulation were consistently provided by the interdisciplinary team. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #10 had diagnoses including quadriplegia, anoxic encephalopathy (brain dysfunction due to lack of oxygen), and seizure disorder.

The resident's most recent Activity Assessment was dated October 5, 2007, and documented the resident enjoyed music, arts and crafts, drawing, cards, games, puzzles, being outdoors and 1:1 visits. The treatment plan noted the resident needed environmental and sensory stimuli, with a listed goal for the resident to be brought to morning activities 5 times a week as tolerated.

The May 26, 2009 "Activity Interest Form" documented the resident's favorite group activities were music, coffee hour, sensory, "busy bees," and sunshine club; and specified the resident enjoyed country style music.

The most recent Minimum Data Set (MDS) assessment, dated April 15, 2011, documented the resident had severe cognitive impairment, was unable to speak, and rarely/never understood others. The MDS documented the resident was totally dependent upon staff for all activities of daily living (ADLs) and had adequate hearing abilities. The MDS did not document the resident's vision abilities.

Physician orders, dated April 20, 2011, documented the resident could participate in activities as tolerated.

The resident's comprehensive care plan (CCP), last reviewed by the interdisciplinary team on April 21, 2011, documented the resident's cognitive functions were impaired due to her diagnosis, and she was non-verbal. The CCP documented the resident was involved in activities some of the time when awake, from 1/3 to 2/3 of the time. Goals listed on the CCP included the resident would not exhibit boredom or isolation. The resident was unable to indicate which activities she would like to attend. Per family, the resident liked music, especially country music. Approaches documented on the CCP included:
- a CD (compact disc) player in her room; bring to music events of interest;
- vary the physical environment when possible; liked being taken outside;
- provide 1:1 visits weekly and as needed for extra stimulation; sit with the resident, talking to her or reading some poems;
- staff must anticipate the activities of interest for the resident.

The undated direct plan of care, used by the CNAs to provide care, documented the resident was non-ambulatory and used a "comfy" chair (specialized recliner chair) when out of bed. The resident's "activity preferences" were left blank (not completed).

Review of the resident's Activity logs dated February 1, 2011 through April 30, 2011, revealed:
- During February 2011, the resident attended a total of 9 activities including 1 music event, four 1:1 visits, and no sensory stimulation activities. There were 22 days when the resident did not receive any activities.
- During March 2011, the resident attended a total of 16 activities, including 1 music event, five 1:1 visits, and no sensory stimulation activities. There were 21 days that month when the resident had no activities.
- During April 2011, the resident attended a total of 15 activities, including 3 music events, three 1:1 visits, and no sensory stimulation activities. There were 17 days that month when the resident received no activities.

Review of the facility's May 2011 Activities Calender for the North and South units revealed these following activities were scheduled during survey:
- May 3, 2011: Guitar Music at 10:30 AM; Current News at 2:30 PM; Sensory Stimulation (fun with music) at 3:30 PM;
- May 4, 2011: "Wii" Bowling at 10:30 AM; Sensory Stimulation at 10:45 AM; Mother's Day reminiscing at 2:30 PM; making Mother's Day cards at 7:30 PM;
- May 5, 2011: Mexican History/Enchiladas; Bingo with the Ladies of Charity at 2:30 PM; "Wii" Bowling at 7 PM.

On May 3, 2011, a surveyor observed:
- at 10:35 AM, Resident #10 was in her room lying in bed awake. There was a small hand written sign taped to the wall next to the resident's window which read, "Do not open Resident #10's window." The blinds covering the resident's windows were closed, the window was shut, the lights were off, and the room was dark. The resident was not present in the unit dining room for the scheduled activity (Guitar Music).
- at 2:30 PM, the resident was in her room lying in bed awake. The door was open, the blinds were closed, the window was shut, and the television was turned on.
- at 4:20 PM, the resident was in her room lying in bed awake; and not present in the unit dining room for the scheduled activity (Fun with Music) which started at 4:10 PM.

On May 4, 2011, a surveyor observed:
- at 8:40 AM, the resident was in her room lying in bed asleep. Her door was open, the window was shut, the blinds were closed, and her radio/CD player was turned off.
- at 10:10 AM, the resident was in her room lying in bed awake. Her door was open, the window was shut, the blinds were closed, and her radio was turned on.
- at 10:25 AM, the resident was in her room seated in her comfy chair and was awake. Her door was open, the window was shut, the blinds were closed, and her radio was turned on.
- at 10:45 AM, the resident was not in the unit dining room for the scheduled activity (Sensory Stimulation).
- at 12:05 PM, the resident was in her room seated in her comfy chair and was awake. Her door was closed, the window was shut, the blinds were closed, the lights were off, and her radio was turned on.
- at 2:45 PM, the resident was in her room lying in bed awake. Her door was open, the window was shut, the blinds were closed, the lights were off, and her radio was on.

On May 5, 2011, a surveyor observed:
-at 9 AM, the resident was in her room lying in bed awake. The door was partially closed, the window was shut, the blinds were closed, the lights and the radio were off.
- at 10:10 AM, the resident was in her room lying in bed awake. The door was open, the blinds were closed, the window was shut, and her radio was turned on.

The Unit Nurse Manager and the Director of Nursing (DON) were interviewed together in the resident's room on May 5, 2011 at 10:18 AM. The DON said when the resident was up in her "comfy" chair, the window blinds should be opened. Both the DON and the Unit Nurse Manager did not know why there was a sign on the wall about the resident's window being kept shut. The DON said the window should be open and the lights should be on during the day in the resident's room. The DON said the resident should be brought out of her room for activities, and the CNAs, nursing and activity staff should be responsible for getting the resident out of her room. The DON said, "this is not care planned."

The Acting Director of Activities was interviewed on May 5, 2011 at 9:35 AM. She said she had not documented any activity assessments for the resident. She stated she only updated the resident's care plan with a note. The Acting Director of Activities said, "I didn't know I was suppose to do them (assessments)."

When the resident's primary CNA was interviewed on May 5, 2011 at 10:30 AM, she said the resident came out of her room "once in a while. We don't always have time to get her ready." The CNA said she had no idea what the resident's activity preferences were. The CNA said the resident's window blinds were always closed, and did not think they were ever opened. The CNA told the surveyor she did not know why the sign about the resident's window was in the resident's room. The CNA said she turned the radio on for the resident. "I just do it, it's not written anywhere. Music seems to quiet her (resident) down."

The Acting Director of Activities was re-interviewed on May 5, 2011 at 12:15 PM. She said the resident was not always up and ready to be brought to a scheduled activity. She was told by the resident's family the resident enjoyed music. "I don't know what else she likes." When asked why the resident had not attended scheduled music programs during the survey, she said, "I cannot answer that." The surveyor asked if the resident was provided with sensory stimulation activities. The Acting Director reviewed the resident's activity logs for February - March 2011 and said it did not look like the activity leader provided sensory stimulation activities with the resident. She said the resident's activities "are not adequate."

In summary, for this resident who was kept isolated in her room for long periods, without activities or sensory stimulation, the facility :
- did not ensure the resident had a current activity assessment that addressed her mental and psychosocial needs;
- did not ensure the CNA direct plan of care specified the resident's activity needs;
- did not ensure activities and sensory stimulation were consistently provided in accordance with the resident's CCP;
- did not ensure the resident's activity goals were consistently met.

2) Resident #7 had the diagnoses of profound mental deficits, dysphagia (difficulty swallowing), and aphasia (inability to express words).

The February 2011 Activity Progress Notes documented the resident attended an activity 8 of 28 days that month. The March 2011 Activity Progress Notes documented the resident attended an activity 11 of 31 days that month. The April, 2011 Activity Progress Notes documented the resident attended an activity 8 of 30 days that month.

The Minimum Data Set (MDS) assessment, dated April 15, 2011, documented the resident had severely impaired cognitive skills; was totally dependent on 2 or more staff to move in bed, to move from the bed to a chair, and to move between locations on the unit.

The resident's comprehensive care plan (CCP), updated on April 13, 2011, documented goals for the resident not to exhibit boredom or isolation; to sit in the hallway and watch other residents and staff. The CCP specified the resident liked music and would keep time with music with his left hand. Interventions included:
- sensory stimulation to enhance resident's involvement, music, and ball tossing.
- staff must anticipate which activities were appropriate for the resident.
- the resident had a CD player/radio in his room, and liked to listen to music. Staff were to provide materials of interest.
- vary the physical environment when possible; the resident liked to be outside when the weather was good.
- praise the resident for involvement in activities.
- provide 1:1 visits as needed for extra stimulation.

The undated direct plan of care, used by the CNAs to provide care, was left blank (not completed) for the resident's "activity preferences".

Review of the facility's Activities Calendar for May 3, 2011 revealed the planned activities were guitar music at 10:30 AM; current news at 2:30 PM; and sensory stimulation (fun with music) at 3:30 PM.

On May 3, 2011, the surveyor observed the resident at 12:07 PM, at 12:35 PM, and at 1:35 PM, to be seated alone in his room in a gerichair, with the overbed light turned on and no music or television playing. The surveyor observed the resident lying in bed with the lights off, and the room quiet, at 3:05 PM, 3:40 PM, 3:50 PM, 4:00 PM and at 4:15 PM.

On May 4, 2011, the surveyor observed the resident seated in a gerichair in his room with the lights on and the room quiet, at 8:45 AM, 9:50 AM and at 10:10 AM.

The Activities Director was interviewed on May 5, 2011 at 12:55 PM and stated, "I know there's not much in the way of activities for him. There's really nothing else I can say, we're trying. I know he likes music, he taps his hand in time to the beat."

In summary, the interdisciplinary team did not ensure activities and sensory stimulation were consistently provided to this resident.

10NYCRR 415.5(f)

Based on observation, record review, and staff interview conducted during the standard survey, it was determined the facility did not ensure 1 of 13 current sampled residents (Resident #10) received care in a manner and in an environment that maintained or enhanced her dignity and respect. Specifically, the facility did not ensure an effective comprehensive care plan (CCP) was developed and implemented that addressed Resident #10's attire, in relation to preventing her from being exposed and having her dignity compromised. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #10 had diagnoses including quadriplegia, anoxic encephalopathy (brain dysfunction due to lack of oxygen), and seizure disorder.

The quarterly Minimum Data Set (MDS) assessment dated April 15, 2011 documented the resident had severe cognitive impairment, was not able to speak, rarely/never understood others, and rarely/never was able to be understood. The MDS assessment documented the resident was totally dependent upon staff for all activities of daily living (ADLs).

The CCP, last reviewed by the interdisciplinary team on April 21, 2011, documented the resident's cognitive functions were impaired, due to her diagnosis, and noted the resident was non-verbal. The CCP documented the resident moved her feet continuously and rubbed her clothing and blankets off herself by moving her hands. Goals listed on the CCP included the resident's needs would be met, and her dignity would be maintained. Approaches listed on the CCP included providing the resident with clothing, blanket, or busy blanket (specialized blanket with sensory objects sewn on to provide stimulation) for dignity. The CCP documented staff kept the resident's door to her room partially closed if she was undressed, and the privacy curtain between the beds would be drawn. The CCP did not address the effectiveness of the resident's attire in maintaining her dignity.

The undated direct plan of care used by certified nurse aides (CNAs) to provide care, documented the resident was non-ambulatory, received nothing by mouth, used a "comfy" chair (specialized recliner chair) when out of bed, and wore a cloth incontinence brief at all times. The plan documented the resident's privacy curtain was to be closed while in bed, and her window was to be kept closed.

On May 3, 2011 at 10:35 AM, the surveyor observed the resident lying in bed dressed in a hospital gown, with a bed sheet over her. There was a small hand written sign taped to the wall next to the resident's window that read, "Do not open Resident #10's window." The blinds covering the resident's windows were closed, and her window was closed. The privacy curtain between the beds was drawn.

On May 3, 2011 at 3:30 PM, the surveyor observed the resident lying in bed, wearing a cloth brief, and was exposed from the waist down. The bed sheet was bunched up around the resident's chest. The resident's door was open, the privacy curtain was drawn between the beds, the lights were off, the window and the blinds were closed.

On May 5, 2011 at 10:10 AM, the resident was observed by a surveyor lying in bed, naked from the waist down. There was a cloth brief on the bed which was not fastened around her lower torso. The resident's hospital gown and bed sheet were bunched up around her chest area. The resident's door was open, the blinds were closed, and the privacy curtain was drawn between the bed.

A recently hired social worker and the consulting social worker for the facility were jointly interviewed in the resident's room on May 5, 2011 at 10:13 AM. Both the new social worker and the consulting social worker observed the resident lying in bed naked from the waist down. The consulting social worker stated, "this is a dignity issue. She (resident) should be covered up." The social worker said she was not familiar with Resident #10, as she was hired by the facility the previous week, and had not met all the residents. The consulting social worker stated, "it's very depressing. She (resident) should be covered up." The new social worker said, "she (resident) shouldn't have been left like that. We need to tell somebody, nursing should be told."

The Unit Nurse Manager and The Director of Nursing (DON) were interviewed together in the resident's room on May 5, 2011 at 10:18 AM, and observed the resident lying in bed naked from the waist down. Shortly after entering the resident's room, the DON pulled the privacy curtain completely around the foot of the resident's bed, as the resident's roommate was in the room, and her visitors had just arrived. The DON and the Unit Nurse Manager said the resident kicked off her sheets. The DON said the resident was checked every 2 hours. When the surveyor asked about the cloth brief which was unfastened, the DON said the resident should have been covered with a brief. The DON said the resident was not able to remove (unsnap) the cloth brief by herself.

In summary, the facility did not ensure Resident #10 had an effective CCP developed and implemented that addressed her clothing needs, to ensure her dignity was not compromised by being left exposed.

10NYCRR 415.5(a)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure 2 of 7 residents reviewed for social services (Resident #10 and 15) were provided with the necessary medically related social services to meet their needs. Specifically, there was no documented evidence Resident #10 had periodic social service assessments, reviews, care plan goals interventions, and evaluations completed. For Resident #15, there was no documented evidence that discharge planning was addressed by social service staff. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #10 had multiple diagnoses including quadriplegia and seizure disorder, and was a resident at the facility for more than a decade.

When the resident's current medical record during survey on May 4, 2011, the most recent social services documentation was dated April 15, 1996. There was no other social service documentation in the resident's record. When the surveyor requested all social service documentation related to this resident, staff provided a "30-Day assessment Data Collection Tool" for mood and behavior patterns, dated May 1, 2000 through October 31, 2000, December 2008 - February 2009, and 3 Mini-Mental State Examinations (MMSE) dated May 30, 2003, February 16, 2007, and February 11, 2008. The MMSEs documented the resident was unable to participate and specified the resident was non-verbal.

The quarterly Minimum Data Set (MDS) assessment, dated April 15, 2011, documented the resident had severe cognitive impairment, was not able to speak, rarely/never understood others, and was totally dependent upon staff for all activities of daily living (ADLs). There was no documented evidence the MDS assessment was completed to determine the resident's vision abilities.

The resident's comprehensive care plan (CCP) was last reviewed and signed by the interdisciplinary team on April 21, 2011. (The social worker's signature was not documented on the care plan conference sheet). The CCP documented the resident received psychotropic medication, and was to be referred to social services as needed. There was no documented evidence the CCP was developed to address the resident's ongoing social service needs, with goals, interventions, and evaluations of those interventions.

On May 4, 2011 at 10:45 AM, the surveyor interviewed both the facility's consulting social worker and the new social worker who was hired the previous week ago. After reviewing the resident's current medical record, the consulting social worker said the resident's medical record should have contained documentation of quarterly social service assessments/reviews, and documentation of any significant changes in the resident's condition. The consulting social worker found no evidence of ongoing social service documentation for the resident in the current medical record, in computerized records, or in the social work office's file cabinet.

In summary, the facility did not ensure the resident was provided with medically related social services including ongoing periodic assessments, and care planning goals, interventions and evaluations, to meet her needs, to maintain her highest practicable physical, mental and psychosocial well-being.

2) Resident #15 was admitted for short term rehabilitation on February 9, 2011 with diagnoses including renal disease, hypertension, and diabetes mellitus. The resident was discharged home on April 7, 2011.

The Resident Social History, dated February 9, 2011, documented the resident was married and had a goal to return home.

The comprehensive care plan (CCP), dated February 9, 2011, documented the resident's plan was for possible short term rehabilitation, with a goal of appropriate placement following rehabilitation. Approaches included involving the family in discharge planning, referral for home care services, and identifying equipment needed for discharge.

The MDS (Minimum Data Set), dated March 30, 2011, documented the resident was independent in cognitive abilities; expected to be discharged to the community; and had an active discharge plan.

The Physical Therapy Discharge Summary, dated March 22, 2011, documented the resident achieved all long term goals for physical therapy.

The Occupational Therapy Discharge Summary, dated April 6, 2011, documented the resident was independent with all activities of daily living (ADLs).

Review of the resident's medical record revealed no documented social service progress notes after the admission social work note dated February 9, 2011.

A nurse practitioner (NP) progress note, dated April 5, 2011, documented the resident's discharge was scheduled for April 5, 2011.

A nursing progress note, dated April 7, 2011, documented the resident was discharged home.

Discharge Instructions, dated April 7, 2011, did not document if services were needed at home, or whether referrals had been made by social service staff.

When the surveyor interviewed the social worker on May 5, 2011 at 3 PM, she stated she started working in the facility after the resident was discharged. She did not know how the previous social worker addressed discharge issues.

In summary, there was no documented evidence medically related social services were provided to ensure the resident and family were prepared for the resident's discharge home, and that social service staff addressed whether referrals for services at home were necessary.

10NYCRR 415.5(g)(1)(i-xv)

Based on staff interview and record review conducted during the standard survey, it was determined for 1 of 13 residents reviewed for preadmission screening and record review (PASRR), Resident #14, the facility did not ensure residents with diagnoses of mental retardation and mental illness were screened to determine if the care and services they needed could be provided by the facility. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #14's preadmission screening and record review (PASRR), dated October 29, 2009, (prior to her admission) documented the resident had a diagnosis of dementia. There was no documentation on this PASRR that the resident's diagnoses included mental retardation or a serious mental illness.

The resident's "medical admission" discharge summary, signed and dated November 4, 2009, documented the resident was admitted for a drug overdose and liver failure on October 11, 2009 and was transferred to a psychiatric unit on October 22, 2009. The summary documented the resident was followed by a mental health center prior to hospitalization. The summary documented the resident "will need to be followed by her primary care physician and mental health facility." The medical history and psychiatric history on their summaries did not document the resident had symptoms of dementia.

The resident's "Diagnostic Problem Sheet", dated November 16, 2009 when the resident was admitted to the faiclity, documented the resident's suicide attempt in October 2009. Other diagnoses included schizoaffective disorder, depression, mild mental retardation, nicotine addiction and Alzheimer's dementia.

Review of the resident's medical record revealed the resident was admitted to a psychiatric hospital on February 14, 2011 for psychosis.

The resident's Patient Review Instrument (PRI), dated February, 21, 2011, documented the resident was in the hospital on the psychiatric unit with a diagnosis of psychosis.

The PASRR dated February 21, 2011 documented the resident had dementia (the source of that diagnosis was not specified.) The PASRR documented the resident did not have diagnoses of mental retardation or serious mental illness.

The hospital discharge summary, dated February 22, 2011, documented the resident was hospitalized because she began to hear voices commanding her to hurt others and herself. The note recorded the resident stated she had been feeling increasingly depressed, and ultimately began hearing voices commanding her to hurt herself or others. The discharge summary recorded the diagnostic impression as psychosis, mood disorder, inadequate coping mechanisms, strained relationships and social supports. There was no documented diagnosis of Alzheimer's dementia during the resident's hospitalization.

The resident's re-admission history and physician, dated March 8, 2011, documented the resident's multiple diagnoses, including depression with schizoaffective disorder, and recent suicidal ideations. The attending physician did not document the resident had a diagnosis of dementia in this assessment.

There was no documented evidence the facility tried to determine if the resident's diagnoses of mental retardation and mental illness (schizoaffective disorder), with recent hospitalizations, met the requirements to do a Level II screen, to determine if the resident's needs could be met at the facility.

The Director of Social Services, responsible for reviewing the PASRR at the time of the resident's admission, and readmission was no longer employed by the facility.

In an interview with the Director of Nursing (DON), on May 5, 2011 at 1 PM, she stated she was now responsible for reviewing the PASRR of residents prior to their admission to the facility. The DON said she was not aware the resident had a diagnoses of mental retardation, or that a Level II screen had not been done regarding her mental illness diagnosis.

In summary the facility did not ensure a resident with diagnoses of mental retardation and mental illness was screened to determine if the care and services needed could be provided in the facility.

10NYCRR 415.11(e)

Based on observation, staff interview, and record review conducted during the standard survey, it was determined the facility did not provide a homelike environment for 2 of 13 current sampled residents, Residents #12 and 14. Specifically, for Resident's #12 and 14, the facility did not hang personal pictures in their rooms as requested. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

- Resident #12 had multiple diagnoses including an anxiety disorder, and bilateral amputations of the lower extremities.

The Minimum data Set (MDS) assessment, dated April 26, 2011, documented the resident was cognitively intact.

Nursing progress notes, dated April 12, 2011 on the 7 AM to 3 PM shift, documented the resident was moved to a new room and tolerated the change without difficulty.

- Resident #14 had diagnoses of schizoaffective disorder, mild mental deficits, and depression.

The Minimum data Set (MDS) assessment, dated February 26, 2011, documented the resident was cognitively intact.

During the resident group meeting with a surveyor on May 3, 2011 at 10:30, Resident #14 stated she moved into her room "about one month ago", and was told she could not hang pictures, because the walls had "just been painted".

On May 5, 2011 at 10:35 AM, Resident #12 told a surveyor that she spoke with the Facilities Director soon after she was moved to her new room, and requested her pictures and her roommate's pictures be hung on the walls. She stated she was told by the Facilities Director that pictures could not be hung in her new room, because the walls had been painted.

On May 5, 2011 at 10:45 AM, the Facilities Director told the surveyor that Resident #12 had pictures hung in her previous room, and the walls had to be repaired when she was moved to her current room. He stated the resident's current room had just been painted and he wanted to wait a few weeks to see if she was still in the same room. When the Facilities Director was asked if he had set a date to hang the resident's pictures, he stated, "no, she hasn't said anything in awhile about hanging anything."

During an interview on May 5, 2011 at 12:15 PM, the Social Services Director stated, "residents can have pictures hung in their rooms, they just need to let someone know and they'll be hung." She stated there was no waiting period.

In summary, the facility did not address Residents #12 and 14's request timely to hang pictures to make their rooms have a homelike environment.

10NYCRR 415.5(h)(1)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the current Department of Health survey was readily accessible to all the facility's residents and visitors, without asking staff for assistance. This resulted in no actual harm with potential for minimum harm.

This is a repeat deficiency from the April 28, 2010 survey.

Findings include:

Upon entrance to the facility on May 3, 2011, and during the initial tour on May 3, 2011 at 10 AM, the 2010 New York State Department of Health (DOH) survey results were observed to be attached to a clip board, and affixed to a wall in the front lobby. The clipboard was located above and slightly behind the reception desk, and could not be accessed, without asking the receptionist for assistance.

When interviewed on May 3, 2011 at 11 AM, the receptionist said the survey results on the wall over the reception desk have been there since she was hired by the facility in November of 2010. The receptionist stated residents and visitors would need to ask her for assistance in order to view the survey results.

During the resident group meeting held on May 3, 2011 at 10:30 AM, one anonymous resident, of the 10 anonymous residents in attendance, said he knew where the DOH survey was located in the facility, and said he asked staff for assistance in obtaining the survey, so he could read it.

When interviewed on May 4, 2011 at 9:50 AM, the Administrator stated the survey results were re-located to the front lobby from the resident lounge area, as the resident lounge area was recently painted. The painting of the resident lounge area was completed on April 8, 2011.

In summary, the facility did not ensure the current survey results were readily accessible to residents and visitors without having to ask staff for assistance.

10NYCRR 415.3 (c)(1)(v)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure 3 of the 6 exhaust fans in the building were operating properly (specifically, 1 fan on the east side of the North Unit; 1 fan in the center of the North Unit; and 1 fan on the west side of the South Unit). This resulted in no actual harm with potential for minimum harm.
Findings include:

There was no detectable exhaust ventilation in the toilet room of resident room #4 when checked on May 3, 2011 between 2:30 PM and 3:30 PM. On May 4, 2011 between 10 AM and 11 AM, there was no detectable exhaust ventilation in the toilet rooms of resident rooms #29, 32, 37, the North Unit soiled utility room, and the beauty shop when checked.

When the Maintenance Director was interviewed on May 3, 2011 at 3:50 PM, he stated he checked the exhaust ventilation monthly on the roof; and did not maintain a record of this check.

During a tour of the roof on May 4, 2011 at 10:25 AM, a surveyor observed 6 exhaust fans serving the nursing units and support areas. Three of the six exhaust fans were not operating (1 fan on the east side of the North Unit; 1 fan in the center of the North Unit; and 1 fan on the west side of the South Unit).

When the Maintenance Director was interviewed on May 4, 2011 at 10:35 AM, he stated he did not know that multiple fans were not operating.

In summary, the facility did not maintain exhaust ventilation in the building in proper operating condition.

10NYCRR 415.29(h)(1) and (i)(3)

Based on record review and staff interview conducted during the standard survey, it was determined the facility did not ensure fire drills were conducted quarterly on each shift, in the last 12 months. Specifically, a required quarterly fire drill was not conducted in the second, third, and fourth quarters of 2010. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

When the Director of Nursing was interviewed on May 4, 2011 at 4:15 PM, she told the surveyor that nursing shifts in the facility were 6:30 AM to 2:30 PM, 2:30 PM to 10:30 PM, and 10:30 PM to 6:30 AM.

Review of the facility's fire drill records on May 5, 2011, revealed no 2010 fire drills documented for:
- the evening shift (2:30 PM to 10:30 PM) in the second quarter of 2010 (April through June);
- the night shift (10:30 PM to 6:30 AM) in the third quarter of 2010 (July through September);
- the day shift (6:30 AM to 2:30 PM) in the fourth quarter of 2010 (October through December).

The Maintenance Director was interviewed on May 5, 2011 at 10:25 AM. He stated other staff scheduled the fire drills prior to 2011. He scheduled the fire drills in 2011, and was aware that fire drills were required to be held quarterly on each shift.

In summary, fire drills were not held quarterly on each shift in 2010.

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