The Brightonian, Inc

Based on staff interviews and record reviews, it was determined that for one of one resident reviewed for food consistencies, the facility did not ensure food was provided and prepared in a form designed to meet their individual needs. Resident #69 was not provided with the correct food consistency. This resulted in no actual harm, with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #69 has diagnoses including dementia and history of dysphagia (difficulty swallowing). The physician orders, dated 9/17/11, included orders for a regular dental soft diet. The Comprehensive Nursing Care Plan (CCP), dated 9/26/11, revealed that the resident has difficulty swallowing and receives a regular consistency as tolerated soft diet. Review of a nursing note, dated 9/28/11, revealed that the resident choked on a hot dog. An 11/14/11 physician note included that the resident choked on a pork chop.

During interviews on 3/8/12 at 11:00 a.m., the Food Service Director (FSD) and the Registered Dietitian both said that residents who have physician's orders for regular dental soft diet should receive ground meat. At that time, the FSD provided documentation that showed the resident received regular meat consistency from 9/17/11 to 11/14/11. The FSD stated that the resident's hot dog and pork chop should have been of ground consistency.

[10 NYCRR 415.14(d)(3)]

Based on observations and resident, family, and staff interviews, it was determined that the facility did not ensure that food was served at proper temperatures for residents dining in three of three resident wings. This affected six of eight anonymous residents (Residents A, B, C, E, F, H) and resulted in a pattern of no actual harm, with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

When asked if the food is served at the proper temperature on 3/5/12 at 11:31 a.m., Resident A stated that maybe once or twice it was hot enough.

When interviewed on 3/5/12 at 1:59 p.m., Resident B stated that the food is not hot; the dinner meal is lukewarm.

When interviewed on 3/6/12 at 9:05 a.m., Resident C stated for most of the meals, the food served is lukewarm.

On 3/8/11 a test tray was requested on the West wing. The food truck arrived on the unit at 7:40 a.m. This tray was not sampled until the last tray was passed at 7:50 a.m. Temperatures were taken using a Taylor #9842 digital thermometer. The temperature of the scrambled eggs was 117.3 degrees () Fahrenheit (F). When sampled at this time with the Food Service Director (FSD), the scrambled eggs tasted lukewarm. The FSD stated that the eggs could have been hotter.

After sampling the test tray, the surveyor returned to the kitchen, where the tray line was still in progress. The surveyor checked the temperature of the eggs being held on the steam table, which registered 147.6F. Eggs had been individually portioned and were being held on the steam table ledge.

[10 NYCRR 415.14(d)(1)(2)]

Based on staff interviews and record reviews, it was determined that for one of three residential units, the facility did not provide for the safe and secure storage of medications. The issues included a lack of accurate accounting of narcotic reconciliation sheets (West Unit). This resulted in a pattern of no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Review of the shift-to-shift narcotic sheets for the West Unit revealed that for December 2011, 35 nursing signatures were missing; January 2012, 14 nursing signatures were missing; February 2012, 22 nursing signatures were missing; and March 2012, 6 nursing signatures were missing.

A review of the 2/2/12 to 3/5/12 West Unit Narcotic Count Verification Record on 3/5/12 at 8:35 a.m. revealed the incoming day nurse's signature was missing. At that time, the Licensed Practical Nurse (LPN) said she did not sign when the count occurred that morning and should have.

When interviewed on 3/8/12 at 1:55 p.m., the LPN Nurse Manager said that the shift-to-shift narcotics sheets had not been signed on several days between December 2011 and March 2012. She stated that the facility's expectation is that the narcotic count verification form be signed daily at the time of the count.

The facility's policy entitled, "Accounting for Narcotic Medications," dated July 2011, requries that at each shift change or change in the nurse responsible for passing medications, all narcotics will be counted by the incoming and outgoing licensed nurses, and the correct results will be documented as witnessed on the narcotic count verification form.

[10 NYCRR 415.18(d)]

713-3.21 Details and Finishes.
Details and finishes shall be designed to provide a high degree of safety for the occupants and shall minimize the incidence of accidents with special consideration for residents who will be ambulatory. Hazards such as sharp corners shall be avoided.

(a) All details shall comply with the following requirement:

(12) Ends of handrail and grab bars shall be constructed to prevent snagging the clothes of residents.

Based on observations and staff interview conducted during the survey, it was determined that the facility did not provide compliant handrails. This affected three of three resident units resulting in no actual harm, with potential for more than minimal harm that is not immediate jeopardy. The finding is:

Observation on 3/5/12 revealed that handrails installed in conjunction with a renovation project are not constructed to prevent snagging the clothes of residents. Interview with the Plant Operations Manager revealed that handrails were also added to the wall near the North end of the East wing.

A waiver has been requested by the facility to allow this condition to remain. The waiver review process has not been completed.

[713-3.21(a)(12)]

713-3.12 Hair and Grooming Areas.

Separate rooms(s) shall be provided for hair care and grooming needs of residents.

The space and equipment provided shall be commensurate with the number of residents within the facility. At least one sink for staff handwashing shall be provided that is trimmed with valves that are operable without the use of hands. There shall be another sink that may be used to wash hair. Resident toilets shall be readily accessible to the hair and grooming area(s).

SS = C

Based on observation and staff interview, it was determined that the facility did not provide a separate handwash sink in the hair and grooming area. This affected three of three resident units and resulted in no actual harm with potential for minimal harm.

On 1/4/11, the "In Grand Style Salon" was observed to have one sink only installed within. During an interview, the Plant Operations Manager said that the salon had been built two to three years ago during a renovation project. Newly constructed hair and grooming areas are required to have a sink for handwashing that is separate from the sink that is used for washing hair.

A waiver has been requested by the facility to allow this condition to remain. The waiver review process has not been completed.

[713-3.12]

Based on observations, staff interviews, and record reviews, it was determined that one of one resident reviewed for activities of daily living concerns, the facility did not provide the necessary services to maintain good grooming. Specifically, Resident #46 did not receive timely fingernail care. This resulted in no actual harm, with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #46 has diagnoses that include dementia. The Minimum Data Set Assessment, dated 12/20/11, revealed that the resident had severe cognitive impairment, required extensive assist of one for personal hygiene, was at times incontinent of bowel and bladder, and was not exhibiting any behaviors. Review of the Certified Nursing Assistant (CNA) Resident-Specific Assignment sheet, dated March 2011, indicated the resident required assist of one for grooming, including nail care and indicated that the resident often refused to let staff comb her hair. Under behavior management, it was blank.

During an observation on 3/5/12 at 10:15 a.m., the resident was lying in bed, uncovered. At that time, the resident was picking at her perineal area with her hands. At 12:30 p.m. that day, the resident was feeding herself. Her fingernails were noted to be long, jagged, and soiled with debris.

In observations on 3/7/12 and again on 3/8/12, the resident's fingernails continued to be long, jagged, and soiled with debris. At 12:30 p.m. on 3/8/12, the resident was observed attempting to feed herself with her hands. After surveyor intervention, the resident's fingernails were cleaned by the Registered Nurse (RN).

In an interview on 3/7/12 at 10:50 a.m., CNA #1 stated CNAs clean and cut the fingernails for residents who are not diabetic. She said that she had not cut Resident #46's fingernails in awhile. On 3/8/12 at 12:20 p.m., CNA #1 stated that she had not done the resident's fingernails again that day. When shown the resident's fingernails, she stated that the debris is most likely food because she often eats with her hands. She added that if she refuses care, she would let the nurse know but that she did not that day.

In an interview on 3/8/12 at 12:30 p.m., the RN stated that the fingernails should be cleaned daily but that sometimes the resident fights. She added that the debris could be food or stool and that she would take care of it immediately.

[10 NYCRR 415.12(a)(3)]

Based on observations, staff interviews, and record reviews, it was determined that for one of three residents reviewed for behaviors, the facility did not ensure that a resident who displayed mental or psychosocial difficulty received appropriate treatment and services. Specifically, Resident #28 did not receive a medically ordered psychology consult. This resulted in no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #28 has diagnoses including a closed head injury following a fall, a stroke with aphasia (difficulty speaking), depression, and dementia. A Comprehensive Nursing Care Plan, dated 12/23/11, revealed that the resident was exhibiting behaviors related to dementia including intermittent rejection of care and had impaired communication due to aphasia.

Review of the medical record revealed the following:

a) There was an order, dated 2/10/12, for a psychology consult for depression and signed off by two nurses.

b) There was an order, dated 2/23/12, for Remeron (anti-depressive medication).

c) A progress note, dated 2/28/12, indicated the resident was demonstrating increased agitation and was unable to voice specific concerns.

d) A 3/1/12 nursing progress note documented the resident had an episode of emesis, increased crying, and increased agitation.

e) There was a medical order, dated 3/2/12, for Seroquel (antipsychotic medication).

In an interview on 3/7/12 at 10:00 a.m., the Licensed Practical Nurse stated that the resident would not let anyone near her and that she was yelling and refusing her medications.

Observations made throughout the day shift from 3/5/12 to 3/7/12 revealed the resident was in bed frequently crying out with care, refusing meals and medications, and spending all morning in bed.

When asked on 3/8/12 at 10:30 a.m., the Nurse Practitioner (NP) reported that she had ordered the psychology consult, but she was unaware that it had never been done. She explained that the resident has had increased anxiety and poor appetite and that if she had known they had a problem with the order or that the family did not want a psychological evaluation, she would have responded.

In an interview on 3/8/12 at 11:00 a.m., the Social Worker (SW) stated that she discussed that order with the Nurse Manager (NM) and that they felt that the resident was not appropriate for psychological services. The SW said that they had spoken to the family several months ago about a psych evaluation, and they did not want the resident to leave the building. When asked if they had a licensed psychological therapist that came to the facility, the SW stated they did, but they did not feel this resident was appropriate for that type of therapy. When asked if they spoke to the family regarding this new order, she replied that they did not. The SW stated that the NM should have informed the NP that the consult was never ordered.

There was no documented evidence in the medical record that the psychology consult was ever ordered or completed.

[10 NYCRR 415.12(f)(1)]

Based on observations, family and staff interviews, and record reviews, it was determined that for 3 of 17 residents reviewed for participation in care planning, facility staff did not ensure that residents were allowed to participate in planning care and treatment or changes in care and treatment. Specifically, facility staff did not ensure that family members were afforded the right to participate in the resident's initial and/or annual care plan meetings (Resident #67) and did not make care plan revisions to reflect changes in ambulation status (Residents #69 and #46). This resulted in no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #69 was initially admitted to the facility on 9/17/11 with diagnoses of status post right hip surgery, dementia, and osteoarthritis.

Review of the September 2011 Certified Nursing Assistant (CNA) Resident-Specific Assignment/Accountability sheet revealed that the resident is non- ambulatory and requires the assistance of two for transfer using a Hoyer lift. The Physical Therapy (PT) discharge note recommendations for nursing, dated 12/12/11, revealed that the resident's ambulation requires one assist with a rolling walker with a wheelchair to follow, one assist for transfers and bed mobility, and would benefit from the nursing ambulation program.

Review of the Rehabilitation Aide Monthly Summary revealed that the resident refused to be ambulated from 1/1/12 to 2/29/12.

Review of the Significant Change Minimum Data Set (MDS) Assessment, dated 2/27/12, revealed that the resident's cognitive skills for daily decision making are moderately impaired and that the resident now needs extensive assistance with transfers and no longer ambulates.

The Comprehensive Care Plan (CCP), dated 3/2/12, shows that the resident has experienced a decrease in activities of daily living and functional ability due to weakness and status post right hip fracture and requires assistance from staff. Team approaches are to use assistive devices as ordered, and Physical Therapy (PT) and Occupational Therapy (OT) to evaluate and treat as needed.

Review of the 3/7/12 PT Rehabilitation evaluation documented that the resident needs two assist for transfers and is non-ambulatory.

Observations, staff interviews, and record review completed on 3/7/12 are as follows:

a) At 9:45 a.m., the assigned CNA said the resident is transferred with two assist and that the resident does not ambulate.

b) At 1:13 p.m., the resident was transferring from her wheelchair onto a shower chair with two assist, and then from the shower chair into bed with two assist. The resident, at that time, was not able to participate in the transfer.

c) At 2:00 p.m., the CNA Resident-Specific Assignment/Accountability sheet had a revised date of 3/7/12. The ambulation status was now a one assist with a hemi walker with wheelchair to follow and one assist with transfers.

d) At 2:15 p.m., the Rehab Aide said that the resident has not ambulated for the past two months and that she reported this information to the PT.

e) At 2:20 p.m., the PT said that he has not seen the resident since 12/12/11 and that the resident was a Hoyer lift when she was first admitted. When she was discharged on 12/12/11, the resident was a one assist with a rolling walker for ambulation and transfers. He also said that if the resident had been declining ambulation for the past two months, then she should probably be discharged from the nursing ambulation program.

f) At 2:30 p.m., the Staff Development/Infection Control Registered Nurse said that she had just written the changes on the September 2011 CNA Resident-Specific Assignment/Accountability sheet based on the 12/12/11 PT recommendations. She also said that it is up to the therapist or the CNAs to let nursing know if there is a change in the resident's ambulation status.

g) At 2:35 p.m., the assigned CNA said the resident has been a two assist with transfers for awhile.

In an interview on 3/8/12 at 8:38 a.m., the Rehab Aide said she reports any changes in the resident's status to her supervisor.

During an interview on 3/8/12 at 8:48 a.m., the PT said he did not recall telling nursing of the resident's ambulation changes, nor could he provide any additional documentation. The PT also said that he evaluated the resident yesterday and decided to discharge the resident from the nursing ambulation program due to pain in both knees, and he changed her transfer status to a two person assist.

2. Resident #46 has diagnoses that include dementia, osteoarthritis, and a status post hip fracture. The MDS Assessment, dated 12/20/11, shows the resident required extensive assist with locomotion on the unit, and no ambulation had occurred for that time period. The CNA Resident-Specific Assignment sheet, dated March 2011, revealed the resident was able to self propel her wheelchair and was able to ambulate with one assist and a walker. The Nursing CCP indicated the resident was at risk for falls, used an assistive device, and that staff were to follow PT recommendations.

During intermittent observations made from 3/5/12 to 3/8/12, the resident was either lying in bed or seated in a stationary chair in the hallway.

Review of a 5/13/11 PT evaluation revealed that the resident was able to self propel her wheelchair and ambulates with a walker and wheelchair to follow.

Review of a 2/29/12 Rehabilitation Recommendations to Nursing revealed that the resident was non-ambulatory and a stand pivot transfer. There were no notes in the record to show the resident could be mobile in a wheelchair.

Interviews on 3/8/12 are as follows:

a) At 12:00 p.m., the CNA stated that the resident had not been able to ambulate or self propel a wheelchair for months now and needs a two person lift for transfers.

b) At 2:45 p.m., the Licensed Practical Nurse (LPN) stated that the resident had not been able to ambulate or self propel a wheelchair for months now and that the Nurse Manager is supposed to update the care plans. She reported that if a resident has a decrease in function, staff should contact PT for a new evaluation and recommendations. The LPN explained that staff not familiar with the resident would think the resident was capable of ambulating and self propelling.

3. Resident #67 was admitted to the facility on 12/24/08 and readmitted on 5/15/11 with a primary diagnosis including dementia.

During an interview on 3/6/12 at 11:03 a.m. , a family member stated that the family had not been invited to the annual care plan meeting.

When interviewed on 3/8/12 at 10:59 a.m., the Social Work Director (SW) stated that a Social Worker does call family to invite them to attend the care plan meeting and will only document in the chart if the family declines. The verification of attendance is the family signing the attendance sheet at the care plan meeting. The SW did not remember if the family was invited to the annual care plan meeting. In addition, she stated that sometimes they forget to sign the attendance sheet.

There were no notes in the medical record to show that family had been invited or had attended a care plan meeting within the last 12 months.

[10 NYCRR 415.11(c)(2)(ii)]

Based on staff interviews and record reviews, it was determined that for one of four residents reviewed for accidents, the facility did not conduct a thorough investigation to rule out neglect. Specifically, the facility did not investigate, to the point of determination, the root cause of two choking episodes. This affected Resident #69, and resulted in no actual harm, with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #69 has diagnoses including dementia and history of dysphagia (difficulty swallowing). Review of the September 2011 Certified Nursing Assistant (CNA) Resident-Specific Assignment/Accountability sheet revealed that the resident wears dentures that require an adhesive for application. Physician orders, dated 9/17/11, were written for a regular dental soft diet. Review of the Comprehensive Care Plan (CCP), dated 9/26/11, revealed that the resident has difficulty swallowing and receives a regular consistency as tolerated diet/soft consistency. A communication log provided by the Food Service Director (FSD) shows the resident was receiving a regular diet on 9/17/11.

Review of a nursing note, dated 9/28/11, revealed that the resident received a hot dog for dinner and that the resident had eaten half of the hot dog when she said it was stuck in her throat. The resident did cough up small pieces of the hot dog.

On 9/29/11, the resident was seen by the Physician's Assistant (PA) for evaluation of swallowing difficulties. The PA's assessment included a plan to continue the regular dental soft diet. There was no Incident/Accident Report provided to show that the facility had determined that the appropriate food consistency had been provided.

Review of a physican note, dated 11/14/11, revealed that the resident was seen for choking while eating lunch. The resident's diet was changed to a pureed consistency, and a Speech Therapy (ST) evaluation was to be ordered.

Review of the ST evaluation, dated 11/15/11, revealed that the resident choked while eating a pork chop at lunch on 11/14/11. The Speech Therapist documented that the resident is currently on a soft diet, but staff reported the resident may have gotten a regular pork chop. Also, the resident has had two choking episodes on meat, and dentures are very loose fitting. Recommendations were made for a pureed diet with thin liquids, aspiration precautions, and to consider a dental consult.

Interviews on 3/8/12 are as follows:

a) At 11:00 a.m., the FSD stated that a resident receiving a regular dental soft diet should be receiving ground meat and that this resident should have received a ground hot dog on 9/28/11 and a ground pork chop on 11/14/11.

b) At 11:32 a.m., the Registered Dietitian (RD) said that she was not aware of the choking episode on 09/28/11. The RD also said that a regular dental soft diet would include ground meat.

c) At 12:00 noon, the Registered Nurse/Nurse Manager said that dietary should be notified when a resident has a choking episode. She did not recall if the dietitian was notified when the resident had the choking episode with the hot dog back in September 2011.

d) At 12:05 p.m., the Licensed Practical Nurse (LPN) recalled the resident choking on a pork chop in November 2011 but could not recall if the meat was ground.

e) At 12:30 p.m., the Director of Nursing said that the facility did not complete an investigation for the two choking episodes to determine whether the resident received the correct consistency diet. She also said that an Incident/Accident Report would only be completed if the resident had required the Heimlich maneuver.

The facility's policy entitled, "Policy of Abuse, Neglect and Mistreatment Investigation," dated October 2000, requires that staff investigate and report any accident/incident where there is reasonable cause for suspicion of staff neglect.

[10 NYCRR 415.4(b)(2)&(3)]

Based on observations, staff interviews, and record reviews, it was determined that for 1 of 17 residents reviewed for professional standards of quality, the facility did not provide services in accordance with professional standards. The issue involved not following the physician orders to obtain a psychology consult to evaluate depression and an Occupational Therapy (OT) evaluation for potential use of a communication board for Resident #28. This resulted in no actual harm, with potential for minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #28 has diagnoses including a closed head injury following a fall, a stroke with aphasia (difficulty speaking), depression, and dementia. Review of the Minimum Data Set (MDS) Assessment, dated 12/16/11, revealed that the resident had moderately impaired cognitive skills, a limited ability in making self understood, and exhibited occasional symptoms of depression. Review of the Comprehensive Nursing Care Plan (CCP), dated 12/23/11, revealed that the resident intermittently rejects care and has difficulty communicating due to aphasia.

Review of the medical record revealed the following:

a) A psychology consult for depression and an OT evaluation for a communication board ordered on 2/10/12 by the Nurse Practitioner (NP) were signed as taken off by two nurses.

b) A physician order was written on 2/23/12 for Remeron (depression).

c) In an assessment, dated 2/28/12, the NP noted that the resident was experiencing increased episodes of agitation and was unable to voice specific concerns.

d) In a progress note, dated 3/2/12, the NP noted increased agitation and a plan to order Seroquel (antipsychotic medication).

e) Nursing progress notes from 2/6/12 to the present documented several episodes of weepy behavior and aggressive behavior towards staff.

There was no documentation that showed that the psychology consult or the OT evaluation were completed as ordered.

Observations made during the day shifts from 3/5/12 to 3/7/12 revealed that the resident frequently cries out while receiving cares, refuses meals and medications, and spends all of the morning in bed.

In an interview on 3/7/12 at 10:00 a.m., the Licensed Practical Nurse stated that the resident would not let anyone near her that day and that she was yelling and refused her pain medication.

Interviews completed on 3/8/12 revealed the following:

a) At 10:30 a.m., the NP stated that she did not know why staff did not follow through with orders for OT and psychology evaluations, dated 2/10/12. The NP stated that she ordered the OT consult because she thought if the resident could express her needs better, her behaviors would improve. The NP said that she did not know the family did not want a psychology evaluation.

b) At 11:00 a.m., the Social Worker (SW) stated that she had discussed this order with the Nurse Manager (NM), and they did not feel this resident was appropriate for psychological therapy due to her demenita and aphasia and that her family did not want her to go out. The SW stated that she should have contacted the family, the physician, and the NP regarding the order for a psychology evaluation and did not. The SW explained that the NM is responsible for ensuring an OT consult is ordered.

c) At 11:10 a.m., the OT stated that she had not received an order for the evaluation.

d) At 1:40 p.m., the Director of Nursing stated that the NM or charge nurse is responsible for filling out the requests for therapy and putting it in the therapy box.

Review of the facility's policy entitled, "Physician Orders," dated June 2010, revealed all orders are to be signed and dated by the nurse and by writing "noted" on the order indicates the orders were completed.

[10 NYCRR 415.11(c)(3)(i]

Based on observations made during the Life Safety Code survey, it was determined that the facility did not provide compliant sprinkler coverage. The issues were related to obstructions of sprinkler heads and to an exterior attached roof that was not protected by sprinkler coverage. This affected three (East, Center, West) of four smoke compartments resulting in a pattern of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. The findings occurred on 3/5/12 and are as follows:

The 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, requires that for standard pendant and upright sprinkler heads, horizontal and vertical distances related to separation between obstructions and sprinkler head deflector plates must conform to Table 5-6.5.1.2, "Positioning of Sprinklers to Avoid Obstructions to Discharge." For example, this table requires obstructions that are within 12 inches of the deflector plate to be even with or higher than the deflector plate.

1. In resident rooms E-6, E-7, E-9, and E-14, the sprinkler head in each room was located within 12 inches of a ceiling-mounted light fixture. The light fixture extended approximately 1 inch below the deflector plates on the sprinkler heads.

2. In resident rooms C-6, C-8, and C-9, the sprinkler head in each room was located within 12 inches of a ceiling-mounted light fixture. The light fixture extended approximately 1 inch below the deflector plates on the sprinkler heads.

3. In resident room W-7, the sprinkler head was located within 12 inches of a ceiling-mounted light fixture. The light fixture extended approximately 1 inch below the deflector plates on the sprinkler heads.

4. In the medical records room of the basement, the sprinkler head was obstructed by plumbing drainage lines that were in close proximity.

The 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, states that sprinklers shall be installed under exterior roofs or canopies exceeding 4 feet (1.2 m) in width.

5. The exterior roof above the door that leads to the North courtyard between the Center and West wings was observed to lack any sprinkler coverage. It is noted that this roof is over 4 feet wide.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.1.6.2, 19.3.5.1, 9.7.1.1; NFPA 13 (1999 edition): 5-6.5.1.2, 5-13.8]

Based on observations made during the Life Safety Code survey, it was determined that the facility did not maintain corridor doors. The issue was related to obstructions to closing of corridor doors. This affected three (East, Center and West) of four resident units, resulting in a pattern of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. The findings involved observations made on 3/5/2012 between the hours of 8:30 and 11:00 a.m. and are as follows:

a) The door to resident room E-9 was obstructed by a wheelchair.

b) The door to resident room C-5 was obstructed by a power bed.

c) The door to resident room W-19 was obstructed from closing by the presence of the electrical cord from an oxygen concentrator located in the doorway.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.3.6.3.3]

Based on observations made during the Life Safety Code survey, it was determined that the facility did not maintain egress pathways. The issue was related to an exit corridor that passed through an intervening room. This affected one (West) of four resident units resulting in a pattern of no actual harm, with potential for more than minimal harm that is not immediate jeopardy. The finding is:

On 3/5/12, the exit corridor of the West wing was evaluated. As the corridor leads to the North, it passes through the West wing Solarium. This solarium has an exit discharge door on its West side.

[10 NYCRR 415.29(a)(2), 711.2(a)(1); 2000 NFPA 101: 19.2.5.9]