Niagara Rehabilitation and Nursing Center

415.26(b) Organization and administration: Governing Body.

The nursing home shall have a governing body, or designated persons functioning as a governing body, that is legally responsible for establishing and implementing policies regarding the management and operation of the facility. The governing body shall notify the New York State Department of Health immediately of anticipated or actual termination of any service vital to the continued safe operation of the facility or to the health and safety of its residents and personnel.

Based on staff interview conducted during an Abbreviated survey (complaint #NY00084648) completed 4/19/10, it was determined that the facility did not ensure compliance with all applicable state laws, rules and regulations for one (Second Floor) of three resident units and the Ground Floor. The facility did not notify the New York State Department of Health of a partial evacuation of residents during a Fire/Smoke Emergency. This was a pattern with no actual harm with potential for minimal harm.

The findings are:

1. Interview with the Administrator on 4/16/10 at approximately 1:10 PM revealed that a Soiled Holding Room fan shorted out in the Service Corridor on the Ground Floor on 4/9/10 at 4:10 PM, resulting in the production of smoke within the facility. The "smoke" incident resulted in a response from the Fire Department with a partial evacuation of residents from the Ground and Second floors. Residents were evacuated from the Ground Floor Lobby and moved to the Ground Floor Dining Room and from resident rooms on the Second Floor Long Corridor and moved to the Second Floor Short Hall. The partial evacuation occurred for approximately 20 minutes.

During the interview on 4/16/10 at 1:10 PM, the Administrator confirmed that he did not notify the New York State Department of Health that there was a disruption of resident services during this fire/smoke emergency.

10NYCRR, 710.1(5)(a)(4), 415.26(b)(13)

Based on observation and staff interview conducted during an Abbreviated survey (complaint #NY00084648) completed 4/19/10 , paths of egress and exit doors located on the Ground Floor Service Corridor were obstructed to less than four feet by bags of soiled linen stored on the floor and a mobile soiled linen receptacle. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 4/16/10 at approximately 1:20 PM revealed the path of egress (corridor) was obstructed to less than four feet at the end of the Ground Floor Service Corridor, closest to the Soiled Linen Holding room. Stored in the corridor was an approximate three foot by three foot by three foot mobile soiled linen receptacle and approximately 8 to 10 bags of soiled linen stored on the floor. Interview with the facility's Maintenance Director at this same time revealed one of the two facility's clothes washing machines had been out of order and laundry is backed up resulting in the overflow of soiled linen into the corridor.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101:19.2.3
2000 NFPA 101: 13-2.3

Based on observation and staff interview conducted during an Abbreviated survey (complaint #NY00084648) completed 4/19/10 , the exit door located on the Ground Floor Service Corridor was obstructed by bags of soiled linen stored on the floor and a mobile soiled linen receptacle. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 4/16/10 at approximately 1:20 PM revealed the Exit Door at the end of the Ground Floor Service Corridor was obstructed by a mobile soiled linen receptacle approximately three foot by three foot by three foot in size and approximately 8 to 10 bags of soiled linen stored on the floor. An interview with the Maintenance Director at this same time revealed one of the two facility's clothes washing machine had been out of order and laundry is backed up resulting in the overflow of soiled linen into the corridor.

10 NYCRR 415.29(a) (2), 711.2(a) (1)
1997 NFPA 101:19.2.1, 7.1
2000 NFPA 101: 13-2.1, 5-1

Based on observation and staff interview conducted during an Abbreviated survey (complaint #NY00084648) completed 4/19/10 , a portable fire extinguisher on the Ground Floor Service Corridor was obstructed by approximately eight bags of soiled linen and a mobile soiled linen receptacle. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 4/16/10 at approximately 1:20 PM revealed the fire extinguisher located at the end of the Ground Floor Service Corridor closest to the Soiled Linen Holding room was obstructed by approximately eight bags of soiled linen and a mobile soiled linen receptacle. An interview with the facility's Maintenance Director at this same time revealed one of the two facility's clothes washing machines had been out of order and laundry is backed up resulting in the overflow of soiled linen into the corridor.

10 NYCRR 415.29(a) (2), 711.2(a) (1)
1997 NFPA 101: 13-3.5.6, 7-7.4.1
2000 NFPA 101: 19.3.5.6, 9.7.4.1
1998 NFPA 10: 4-3.2(b)

Based on observation and staff interview conducted during an Abbreviated survey (complaint #NY00084648) completed 4/19/10 , soiled linen was not properly stored. Issues include total gallons of stored soiled linen receptacles and bags of soiled linen on the floor in one space exceeding the minimum square feet of space required to safely store the receptacles. This affected the Ground Floor Service Corridor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 4/16/10 at approximately 1:20 PM revealed a nine cubic foot (3ft by 3ft by 3ft.) mobile soiled linen receptacle that was overflowing with plastic bags full of soiled linen and eight additional bags of soiled linens on the floor, stored unprotected in the service corridor. Observation of the Soiled Holding room revealed the room was full to capacity with soiled linens. Interview with the facility's Maintenance Director at this same time revealed one of the two facility's clothes washing machine had been out of order and laundry is backed up resulting in the overflow of soiled linen into the corridor.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1997 NFPA 101: 13-7.5.5
2000 NFPA 101: 19.7.5.5