Elderwood Health Care at Birchwood

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the resident environment was maintained free of accident hazards in 1 of 28 resident rooms sampled, the room of Resident #25. Specifically, for Resident #25 there was a 1 gallon bottle of bleach (sodium hypochlorite solution) stored in her toilet room during the survey. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

Resident #25 had a diagnoses of dementia and Parkinson's disease.

The Minimum Data Set assessment dated January 25, 2012 documented the resident was moderately impaired cognitively.

The resident's comprehensive care plan dated February 7, 2012 documented the resident was at risk for falls, the goal was to maintain resident safety, and the approaches included provide a safe environment.

A physician progress note dated February 22, 2012 documented the resident had severe dementia.

The resident's room was observed on March 6, 2012 between 11 AM and 11:40 AM. There was a half full bottle of scented bleach on the floor of the toilet room with a sign attached to the bottle with a rubber band; the sign read "do not touch." The bottle of bleach remained in the toilet room when the room was observed again on March 6, 2012 at 3:45 PM, and on March 7, 2012 at 10 AM.

On March 7, 2012 between 10 AM and 10:15 AM:
- A Housekeeper on Resident #25's wing was interviewed. She stated she was part time, and did not normally work on Resident #25's wing. She stated she would not expect to find bleach or other cleaning products left in a resident toilet room.
- The Director of Housekeeping was interviewed and observed the bottle of bleach in the toilet room. She stated the specific bleach in this room was not stocked by either housekeeping or dietary, and removed the bleach at 10:10 AM.
- The surveyor tested the bleach with a test strip (from the roll of test strips used to test the bleach concentration in the kitchen dishwasher rinse cycle); the test strip tested positive for bleach.

On March 7, 2012 at 11:40 AM, the Director of Housekeeping stated to the surveyor that she had determined the bleach had been brought in by a resident's family member for personal laundry.

In summary, the facility did not ensure the resident's room was free of accident hazards.

10NYCRR 415.12(h)

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the nurse call system was operating properly in 2 of 28 resident rooms sampled, the room of Residents #26 and 27 (on Unit 1) and the room of Resident #28 (on Unit 2). Specifically, the nurse call cords, in the toilet rooms, adjacent to the toilet were not operating properly (did not consistently turn on the nurse call system when pulled). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

1) Resident #26 had diagnoses including a fractured femur (hip) and hypertension.

The comprehensive care plan dated January 10, 2012 documented under Safety an approach to "keep call light within reach and encourage use when resident is in room."

The MDS dated February 17, 2012 documented the resident was cognitively intact.

2) Resident #27 had diagnoses including a fractured knee cap and hypertension.

The comprehensive care plan dated February 23, 2012 documented under Safety an approach to "keep call light within reach and encourage use when resident is in room."

The Minimum Data Set assessment dated March 1, 2012 documented the resident's cognitive status was modified independence.

The room of Residents #26 and 27 was observed on March 5, 2012 between 3 PM and 3:20 PM. The nurse call cord in the toilet room was tied around the grab bar adjacent to the toilet. When a surveyor pulled the end of the nurse call cord multiple times, the nurse call system did not turn on.

The nurse call cord remained wrapped around the grab bar in the toilet room on March 6, 2012 between 3:45 PM and 4 PM, and March 7, 2012 at 10:20 AM.

Two Unit 1 CNAs (certified nurse aides) were interviewed on March 7, 2012 between 10:25 AM and 10:35 AM. Both CNAs stated they had not wrapped nurse call cords around the grab bars. They stated in the past, there were residents who needed or requested modifications to the placement of the toilet room nurse call cords.

The Unit 1 registered nurse (RN) Unit Manager was interviewed on March 7, 2012 at 10:40 AM. She stated the placement of the nurse call stations in the resident toilet rooms made it hard for some residents to access the nurse call system. The RN said the nursing staff might have modified the nurse call cords. She stated both residents were able to use the nurse call system. The RN said if the nurse call system needed to be modified to improve accessibility, staff could notify maintenance to make modifications.

3) Resident #28 had diagnoses including hypertension, dementia, kidney disease and depression.

The MDS (Minimum Data Set) dated December 29, 2011 documented the resident was cognitively intact.

The comprehensive care plan dated January 9, 2012 documented planned interventions for bladder continence including to "keep call light in reach."

When the resident's room was observed on March 6, 2012 between 11 AM and 11:40 AM, there was a piece of gauze attached to the nurse call cord in the toilet room. The nurse call cord was wrapped around the grab bar adjacent to the toilet. When the surveyor tested the nurse call system by pulling the end of the cord, the nurse call system did not turn on 3 of the 5 times the cord was pulled.

The nurse call cord remained wrapped around the grab bar when the resident's room was observed on March 6, 2012 at 4 PM.

In summary, the facility did not ensure the nurse call system was operating properly in 2 resident rooms.

10NYCRR 415.29

Based on observation and staff interview conducted during the standard survey, it was determined the facility did not ensure the main oxygen storage room had adequate ventilation as required by NFPA 99, Standard for Health Care Facilities. Specifically, the main oxygen storage room contained at least 55 'E' (small) full oxygen tank and had no exhaust ventilation. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.
Findings include:

The main oxygen storage room was observed on March 7, 2012 between 9:30 and 10 AM. The room contained at least 55 full 'E' tanks of oxygen. There was no ventilation grille in the room.

The Plant Operations Director was interviewed on March 7, 2012 between 9:30 and 10 AM. He stated there was no ventilation in the main oxygen storage room, and he understood why ventilation was required.

In summary, the main oxygen storage room did not have ventilation, as required.

10NYCRR 415.29((a)(1&2), 711.2(a)(20), 1999 NFPA 99 4-3.1.1.2(c)