Niagara Rehabilitation and Nursing Center

Based on record review and staff interview, the facility did not implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property. Four (Employees #1, 2, 3, 4) of five employee files reviewed lacked timely verification with the State Nurse Aide Registry prior to employment. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. During the Abuse Protocol review, five employee files were reviewed. Four of five employee files revealed that the State Nurse Aide Registry was not checked until after the employees were hired.

Review of Employee #3's file revealed the Dietary Aide was hired on 3/16/11 and the State Nurse Aide Registry check was performed on 6/2/11.

Review of Employee #4's file revealed the Maintenance Staff was hired on 3/16/11 and the State Nurse Aide Registry check was performed on 6/3/11.

Review of Employee #1's file revealed the certified nurse aide (CNA) was hired on 6/15/11 and the State Nurse Aide Registry check was performed on 7/12/11.

Review of Employee #2's file revealed the CNA was hired on 6/22/11 and the State Nurse Aide Registry check was performed on 7/5/11.

Review of a facility policy entitled Prevention of Mistreatment, Neglect, Abuse, and Misappropriation of Resident Property with a revised date of 8/08 revealed "All potential employees will be checked against the State Nurse Aide Registry regardless of position applied for".

During interview on 7/12/11 at 1:30 PM, the Human Resources (HR) Specialist stated that the position was new to her, and she was not aware of the fact that it was required to check all of the employees against the nurse aide registry before their hire date.

415.4(b)(i)(ii)(b)

Based on record review and staff interview, the facility did not develop a comprehensive care plan that includes measurable objectives and timetables to meet a resident's medical needs, to attain or maintain the resident's highest practicable physical, mental and psychosocial well-being. Three (Residents #12, 25, 46) of 25 residents reviewed for comprehensive care plans did not have care plans developed for mental health services or anxiety with the use of a psychotropic medication. There was no actual harm with potential for more for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #12 has diagnoses that include schizophrenia, dementia, congestive heart failure and BPH (benign prostatic hypertrophy - enlarged prostate). Review of Social Work Resident Progress Notes dated 3/15/11 revealed the resident was admitted from a Psychiatric Center on 3/9/11. Review of the admission Minimum Data Set (MDS) dated 3/18/11 revealed the BIMs (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score as 12/15 (moderate cognitive impairment) and a discharge back to the community is not feasible.

Review of a Notice of Determination of The Need For Specialized Services dated 3/8/11 revealed the resident was admitted with recommendations that included:

- a Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care;
- twice monthly initial follow up by mental health worker
- therapeutic group treatment at least twice weekly.

Review of the Comprehensive Care Plan Cover Sheet revealed the Care Plan was reviewed on 3/29/11 and 6/14/11. The Care Plan dated 6/15/11 identified the resident with schizophrenia and a history of physical and verbal aggressive behavior, threatening staff and other residents, along with social inappropriateness. Further review of these care plans revealed they do not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

Interview with the Registered Nurse (RN) Unit Coordinator (UC) on 7/13/11 at 1:45 PM revealed that to her knowledge the resident does not see the psychologist for any therapy, but does attend group activity programs at least two times per week. The Unit Coordinator said she was aware of the Level II PASRR but did not read through all of the requirements or recommendations listed.

Interview with the Director of Activities on 7/13/11 at 2:00 PM revealed that the resident does attend activities programs several times per week.

2. Resident #25 has diagnoses including schizophrenia, bipolar disorder, anxiety state, diabetes mellitus, and hypertension. Review of the Minimum Data Set (MDS) revealed the resident was originally admitted on 2/11/11 and re-admitted on 3/25/11 and 5/26/11. Further review of MDS information revealed the resident's BIM score was 15/15 (cognitively intact) on the Significant Change MDS dated 5/5/11 and the resident is understood and understands.

Review of the PASRR dated 5/26/11 revealed the resident required a Level II for Possible Mental Illness.

Review of the Notice of Determination of the Need For Specialized Services dated 1/7/11 and 5/26/11 revealed the resident required the following:

- "Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care
- twice monthly initial follow up by mental health worker
- therapeutic group treatment at least twice weekly".

Review of the untitled care plan meeting notices dated 3/1/11 and 4/12/11 revealed the resident's Comprehensive Care Plan was reviewed on 3/1/11, 4/12/11 and 5/11/11 which is the current Care Plan. The care plan identified the resident with schizophrenia, anxiety, depression, and verbally aggressive behavior, threatening staff and other residents, and with potential for inappropriate touching. The resident's Comprehensive Care Plans does not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

During an interview with the Registered Nurse (RN) Unit Coordinator (UC) on 7/13/11 at approximately 9:00 AM, the RN UC stated "I would need to speak to the resident's Social Worker regarding the Level II PASRR recommendations for the resident because I am new to the unit and any recommendations should be incorporated into the care plan at the care plan meetings".

3. Resident #46 has diagnoses including diabetes mellitus, deep vein thrombosis (DVT - blood clot), coronary artery disease and depressive disorder. Review of the resident's most recent Minimum Data Set (MDS) revealed that the resident is understood and understands with a BIMS score of 11 (moderately impaired).

Review of the resident's Comprehensive Care Plan dated 12/29/10 revealed a plan was developed for the resident triggering for mood related to depression. There is no mention of the use of Xanax for anxiety, as ordered by the physician on 7/7/11 and recommended by the Psychiatry Consult of 6/5/11, in the care plan.

During an interview with the Registered Nurse (RN) Unit Coordinator (UC) on 7/13/11 at 4:35 PM, the RN stated "I spoke with the Social Worker who usually writes the care plan for mood and behavior. I told her that we currently do not have a care plan for the use of Xanax for anxiety for this resident. She reviewed the care plan and said that she was surprised that there was nothing there. I do not see any entry in the care plan for Xanax".

Further interview with the RN UC on 7/14/11 at 9:00 AM revealed that she spoke to the Director of Nursing (DON) on 7/13/11 about the care plan for the use of psychoactive meds, such as Xanax. The RN explained "it was clarified for me that it is my responsibility to include psychoactive medications in the care plan. We have a new computer system that I've been learning for the last 3 months, and I'm converting the old care plans to the new system, I'm including the medication care plans in this process. I have rewritten her care plan, including the anticoagulant and depression section and added a section for anxiety and the use of Xanax".

415.11(c)(1)

Based on record review and staff interviews, it was determined that one (Resident #46) of 10 residents reviewed for unnecessary medications did not have their care plan revised to reflect a change in Coumadin dosage. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #46 has diagnoses which include diabetes mellitus, deep vein thrombosis (DVT-blood clot), coronary artery disease and depressive disorder. Review of the resident's most recent Minimum Data Set (MDS) dated 4/30/11 revealed that the resident is understood and understands with a Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) score of 11 (moderately impaired cognition).

Review of Physician Orders dated 6/16/11 to 7/7/11 revealed an order dated 6/16/11 to increase Coumadin (blood thinner) to 4.5 milligram (mg) by mouth (po) daily at 5:00 PM and to discontinue previous Coumadin order and an order dated 7/7/11 for Coumadin 2.5 mg tablets and Coumadin 2 mg tablets, take 1 of each to make a total dose of 4.5 mg once a day at 5:00 PM.

Review of the resident's Comprehensive Care Plan (CCP) Problem/Strengths: High risk for hemorrhage related to use of anticoagulant, Coumadin Therapy secondary to Deep Vein Thrombosis Prophylaxis (prevention of disease) revealed a revision, dated 4/7/11, that the resident is " Presently on Coumadin 4 mg po " .

During an interview with the Registered Nurse (RN) Unit Coordinator (UC) on 7/13/11 at 4:35 PM, the RN stated that she made the entry on 4/7/11 in the care plan for the Coumadin 4 mg. When the Coumadin dose was increased by the physician to 4.5 mg she did not make the appropriate revision to the care plan.

415.11(c)(2)(iii)

Based on record review and staff interview, it was determined that the facility did not provide required mental health rehabilitative services or obtain the required services from an outside source. Two (Resident #12, 25) of two residents reviewed for specialized services did not receive the recommended mental health services that included twice monthly initial follow up by a mental health worker. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #12 has diagnosis that includes schizophrenia, dementia, congestive heart failure and benign prostatic hypertrophy (BPH-enlargement of the prostate). This resident was admitted from a Psychiatric Center on 3/9/11, and his admission Minimum Data Set (MDS) dated 3/18/11 documents his brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) score as 12/15 and a discharge back to the community is not feasible.

Review of a Notice of Determination of the Need For Specialized Services dated 3/8/11 revealed the resident was admitted with a Level II PASRR required recommendation that included:

- a Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care;
- twice monthly initial follow up by mental health worker
- therapeutic group treatment at least twice weekly.

Review of the Comprehensive Care Plan (CCP) Cover Sheet revealed the Comprehensive Care Plan was reviewed on 3/29/11 and 6/14/11. The Care Plan dated 6/15/11 identifies the resident with schizophrenia and a history of physical and verbal aggressive behavior, threatening staff and other residents, and with social inappropriateness. The Care Plans do not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

Interview with the Registered Nurse (RN) Unit Coordinator on 7/13/11 at 1:45 PM revealed that to her knowledge the resident did not see the psychologist or a mental health worker for any initial therapy or additional follow up.

Interview with the Social Worker (SW) on 7/14/11 at 1:05 PM revealed she was aware of the Level II PASRR required recommendations that were included with the resident's readmission on 3/9/11 and stated she wished the facility had a mental health worker available to provide the services, then subsequently confirmed the facility does employ a clinical psychologist.

2. Resident #25 has diagnoses including schizophrenia, bipolar disorder, anxiety state, diabetes mellitus, and hypertension. Review of the Minimum Data Set (MDS) revealed the resident was originally admitted on 2/11/11 and re-admitted on 3/25/11 and 5/26/11. Further review of the MDS revealed the resident's Brief Interview for Mental Status (BIMS-a brief screen that aids in detecting cognitive impairment) score was 15/15 cognitively intact on the Significant Change MDS dated 5/5/11 and the resident is understood and understands.

Review of the PASRR dated 5/26/11 revealed the resident required a Level II for Possible Mental Illness.

Review of the Notice of Determination of the Need For Specialized Services PASRR dated 1/7/11 and 5/26/11 revealed the resident required the following:

- Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care
- twice monthly initial follow up by mental health worker
- therapeutic group treatment at least twice weekly.

Review of the current Comprehensive Care Plan dated 5/11/11 identifies the resident with schizophrenia, anxiety, depression, and verbally aggressive behavior, threatening staff and other residents, and with potential for inappropriate touching. The resident's Comprehensive Care Plans (CCP) does not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

Interview with the Registered Nurse (RN) Unit Coordinator (UC) on 7/13/11 at approximately 9:00 AM revealed the RN UC stated that I would need to speak to the resident's Social Worker regarding the IPRO recommendations.

Interview on 7/13/11 at approximately 2:30 PM with the Director of Social Work revealed she was aware of the Level II PASRR recommendations but they did not have group therapy at the facility and the psychologist does not come to the facility regularly.

Interview with the resident's Social Worker on 7/14/11 at approximately 3:30 PM revealed the Social Worker stated she was aware of the Level II PASRR recommendations. The Social Worker was asked about the twice monthly follow-up by a Mental Health Worker recommendation from the Level II PASRR and she stated she was aware of the recommendations but stated "they are only recommendations". Further review with the Social Worker revealed the psychologist only comes in maybe once a month. The Psychological Service Notes from the psychologist dated 2/23/11, 4/27/11 and 7/6/11 were reviewed and discussed with the Social Worker. The Notes documented the resident has not seen the psychologist/Mental Health Worker twice a month as per the Level II PASRR recommendations and the resident had also been hospitalized at a psychiatric facility. The Social Worker stated the psychologist doesn't come to the facility regularly and has also been on vacation. In addition the Social Worker stated the facility does not have a policy but only the training manual - Instruction Manual for SCREEN Form that they follow.

415.16(a)(1)(2)

Based on record review and staff interview, the facility did not provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. Two (Residents #12, 25) of two residents reviewed for PASRR (Pre-Admission Screen and Resident Review) Level II recommendations had issues involving the lack of social work follow up and advocation for residents with mental illness who required specialized services as recommended by their PASRR determinations. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #12 has diagnoses that include schizophrenia, dementia, congestive heart failure and BPH (benign prostatic hypertrophy - enlarged prostate). Review of Social Work Resident Progress Notes dated 3/15/11 revealed the resident was admitted from a Psychiatric Center on 3/9/11. Review of the Minimum Data Set (MDS) dated 3/18/11 documents his BIMs (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score as 12/15 (moderately impaired cognition) and a discharge back to the community is not feasible.

Review of a Notice of Determination of the Need For Specialized Services dated 3/8/11 revealed recommendations that included:

- a Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care;
- twice monthly initial follow up by mental health worker
- therapeutic group treatment at least twice weekly.

Review of the Comprehensive Care Plan Cover Sheet revealed the Comprehensive Care Plan was reviewed on 3/29/11 and 6/14/11. Review of the Care Plan dated 6/15/11 identified the resident with schizophrenia and a history of physical and verbal aggressive behavior, threatening staff and other residents, along with social inappropriateness. The Care Plans do not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

Review of the Medical Record revealed no documented evidence that the resident received twice monthly follow-up by a Mental Health Worker.

Interview with the Social Worker (SW) on 7/14/11 at 1:05 PM revealed she was aware of the Level II PASRR required recommendations that were included with the resident's readmission on 3/9/11 and stated she wished the facility had a mental health worker available to provide the services. The SW then subsequently confirmed the facility does employ a clinical Psychologist.

2. Resident #25 has diagnoses including schizophrenia, bipolar disorder, anxiety state, diabetes mellitus, and hypertension. Review of the Minimum Data Set (MDS) revealed the resident was originally admitted on 2/11/11 and re-admitted on 3/25/11 and 5/26/11. Further review of MDS information revealed the resident's BIMs (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score was 15/15 (cognitively intact) on the Significant Change MDS dated 5/5/11 and the resident is understood and understands.

Review of the PASRR dated 5/26/11 revealed the resident required a Level II for Possible Mental Illness.

Review of the Notice of Determination of the Need For Specialized Services dated 1/7/11 and 5/26/11 revealed the resident required the following:

- Psychiatric evaluation within 14 days after admission or a written psychiatric plan of care;
- twice monthly initial follow up by mental health worker,
- therapeutic group treatment at least twice weekly.

Review of a Psychiatry Consult dated 3/4/11 revealed the resident was not seen within 14 days of admission as recommended.

Review of the untitled care plan meeting notices dated 3/1/11 and 4/12/11 revealed the resident's Comprehensive Care Plan was reviewed on 3/1/11, 4/12/11 and the current Care Plan was dated 5/11/11. The care plan identifies the resident with schizophrenia, anxiety, depression, verbally aggressive behavior, threatening staff and other residents, and potential for inappropriate touching. The resident's Comprehensive Care Plans does not identify that the resident requires follow up by a mental health worker, or that he should attend therapeutic group treatment at least twice weekly.

Interview on 7/13/11 at approximately 2:30 PM with the Director of Social Work revealed she was aware of the Level II PASRR recommendations but the psychologist does not come to the facility regularly.

During an interview with the resident's Social Worker on 7/14/11 at approximately 3:30 PM, the Social Worker stated she was aware of the Level II recommendations. The Social Worker was asked about the Level II recommendations for twice monthly follow-up by a Mental Health Worker and she stated she was aware of recommendations but stated "they are only recommendations". The Social Worker also stated the psychologist only comes in maybe once a month. Reviewed and discussed with the Social Worker the Psychological Service Notes from the psychologist dated 2/23/11, 4/27/11 and 7/6/11 and that the resident has not seen the psychologist/Mental Health Worker twice a month per the Level II recommendations and the resident had also been hospitalized at a psychiatric facility. The Social Worker explained the psychologist doesn't come to the facility regularly and has also been on vacation.

415.5(g)(1)(iii)

THIS IS REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 6/16/10.

Based on observation and record review during a Life Safety Code survey, structural components of the facility were not properly protected from fire. Issues include structural steel trusses/joists and beams, located above the non-fire rated ceiling assembly that were not protected to meet minimum fire rated building construction type II (222). This affected four (1, 2, 3, 4) of four resident use floors. This was widespread with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. The Centers for Medicare & Medicaid Services (CMS) recognizes the 2001 edition of NFPA 101A, Guide on Alternative Approaches to Life Safety, (also known as the Fire Safety Equivalent System or FSES). This standard provides alternative approaches to life safety based on equivalent safety concepts. A building determined to have equivalent safety requirements of the National Fire Protection Association, NFPA 101, Life Safety Code, is deemed to be compliant for the identified deficient requirement.

Per NFPA 101 Life Safety Code, 2000 edition, the minimum acceptable construction type for this four story building is type II (222). Per NFPA 220 Standard on Types of Building Construction, 1999 Edition, Construction type II (222) requires that structural components (Exterior load bearing walls, Structural Framing (columns, girders, beams, etc.) and Floor construction) are protected with at least a two-hour fire resistive barrier. This can be accomplished by providing some type of physical two-hour fire rated protective covering on the structural steel components or by maintaining a two-hour fire rated ceiling assembly.

Observation of the First, Second, Third and Fourth floors on 7/11/11 from approximately 9:00 AM until 3:00 PM revealed this building is protected by a complete automatic sprinkler system.

Observation of all four resident use floors on 7/12/11 from approximately 9:30 AM until approximately 10:20 AM revealed the ceilings located throughout the facility corridors and select resident use rooms are comprised of lay in ceiling tile assemblies. Most resident room ceilings are monolithic (solid) ceilings. The fire resistance rating of these ceilings could not be determined from a review of facility blueprints during a recertification survey on 6/16/10. Furthermore, the facility did not provide documentation of a two-hour fire resistive rated ceiling assembly. Observations above the ceiling tiles on floors One, Two, Three and Four at these same times on 7/12/11 revealed unprotected structural steel trusses/joists throughout all four floors of the facility. These observations confirm there has been no change to the fire protective rating of the steel beams and web trusses in this facility.

Steel structural I-beams were protected with a spray-on fire resistive coating in some areas of the building but not throughout the building as required. Because the steel I-beams and trusses are not protected by a spray on fire resistive coating or protected by a two-hour fire rated ceiling assembly, the building is not compliant per NFPA 101 2000 edition and NFPA 220.

The results of a "Fire Safety Evaluation System" (FSES) dated 8/10/10 shows the facility is in compliance with this aspect of the Life Safety Code provided that the facility maintains specific physical requirements. After a review of the FSES and observations made throughout the facility from 7/11/11 through 7/13/11, it was determined that the facility is in compliance with this provision of the Life Safety Code based on the FSES.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 19.1.6.2, 19.3.5.1, 4.6.6, 19.1.1.4.1
1999 NFPA 220: 3-1

Based on observation during a Life Safety Code survey, corridor doors were obstructed from closing by trash cans, tables, towels, a brick, wheelchairs, walkers and a wooden door wedge. This affected three (Units Two, Unit Three, Unit Four) of three resident units and the First Floor. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to the following:

1. Observation on 7/11/11 at approximately 10:00 AM revealed the corridor door to the First Floor Staff Dining Room was obstructed from closing by a trash can.

2. Observation on 7/11/11 at approximately 10:00 AM revealed the corridor door to the First Floor Elevator Machine Room was obstructed from closing by a brick.

3. Observation on 7/11/11 at approximately 12:38 PM revealed the corridor door to the First Floor General Storage room in the Service Corridor, was obstructed from closing by a wooden door chock (wedge) pressed under the door. This door is equipped with a self closing mechanism. The door was again observed propped open with the wooden door wedge on 7/12/11 at approximately 9:16 AM.

4. Observation on 7/11/11 at approximately 2:55 PM revealed the corridor door to resident room #433 on Unit Four was obstructed from closing by an unoccupied wheelchair.

5. Observation on 7/11/11 at approximately 2:58 PM revealed the corridor door to resident room #309 on Unit Three was obstructed from closing by a walker.

6. Observation on 7/12/11 at approximately 9:15 AM revealed the corridor door to the First Floor Ladies Locker room in the Service Corridor, was obstructed from closing by a towel wedged up above the door's self closing mechanism.

7. Observation on 7/12/11 at approximately 2:50 PM revealed the corridor door to resident room #313 on Unit Three was obstructed from closing by an over bed table with an oxygen concentrator underneath it.

8. Observation on 7/12/11 at approximately 2:55 PM revealed the corridor door to resident room #218 on Unit Two was obstructed from closing by a trash can.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.6.3, 19.3.6.3.2

Based on observation and staff interview during a Life Safety Code survey, a smoke barrier door was not properly maintained. Issues included a smoke barrier door that did not fully close. This affected the Ground Floor. 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 7/13/11 at approximately 11:40 AM revealed the smoke barrier doors that separates the Ground Floor Service Corridor from the rest of the Ground Floor did not fully close. Each of the doors strike one another leaving the door open approximately one and a half inches. An interview with the Maintenance Director on 7/13/11 at approximately 1:15 PM revealed these doors were recently painted.

10 NYCRR 415.29(a)(2),711.2(a)(1)
2000 NFPA 101: 19.3.7.6, 19.2.2.2.6

THIS IS REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 6/16/10.

Based on observation, record review and staff interview during a Life Safety Code survey, two of two elevators were not equipped with Fire Fighters Service Phase II emergency in-car key operation. This affected four (First, Second, Third, Fourth) of four resident use floors. 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 7/11/11 at approximately 9:30 AM revealed there are two elevators in the facility that serve the First, Second, Third and Fourth Floors. During the standard recertification Life Safety Code Survey with the exit date of 6/16/10, the travel distances of these elevators were determined to exceed 25 feet in length. These distances were determined by counting the steps in the rear stairwell from the ground floor landing to the fourth floor landing. There were 48 steps. The height of each stair riser was 7.5 inches high. When the number of steps was multiplied by the height of the risers the final number was 360 inches (30 feet). Elevators with a travel distance of 25 feet or more are required to be equipped with both Phase I and Phase II elevator recall per NFPA 101 Life Safety Code 2000 edition.

Observation inside the elevator cabin on 7/11/11 at approximately 9:20 AM revealed there was no evidence (by way of buttons or labeled key operation features) of Phase II emergency in-car key operation.

Review of a time limited waiver, approved by CMS for installation of the Phase II Fire Fighter recall feature revealed that this waiver expired on 7/9/11 and the installation had not begun. An interview with the Director of Maintenance on 7/12/11 at approximately 10:30 AM revealed that a start date has not been established to begin this project as the facility is in process of securing funding. A copy of a signed contract with the Elevator Maintenance Company dated 4/11/11 was reviewed on 7/11/11.

In keeping with new guidance from CMS, a revised time limited waiver must be requested. Please include in your Plan of Correction, a request for a Time Limited waiver and include the following:

a). Justification for the waiver.
b). Timetable with milestones of major activities leading to correction.
c). All interim life safety measures that will be undertaken.

2000 NFPA 101: 19.5.3, 9.4
10 NYCRR 415.29(a)(2), 711.2(a)(1)

THIS IS REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 6/16/10.

Based on observation during a Life Safety Code survey, corridor means of egress were not continuously maintained free of all obstructions. This affected three (Unit Two, Unit Three, Unit Four) of three resident units and the Ground Floor. The issue includes passable space in the corridor that is limited to less than four feet due to storage of unoccupied wheelchairs and geri chairs and laundry equipment stored in the corridor. Also, exit doors are obstructed by chairs. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to the following:

1. Observation on 7/11/11 from 9:50 AM until 9:55 AM revealed the Unit Two corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following locations by the following items:

a). approximately 35 inches at Room #229 by an open, unoccupied wheelchair
b). approximately 37 inches at Room #229 by an open, unoccupied wheelchair

2. Observation on 7/11/11 at approximately 10:42 AM revealed one of three doors in the Ground Floor Dining Room labeled "EXIT" were obstructed by two dining room chairs that were in front of the door. Further observation on 7/13/11 at approximately 11:31 AM revealed the same door was again obstructed by two dining room chairs.

3. Observation on 7/11/11 from 2:46 PM until 2:55 PM revealed the Unit Four corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

a). approximately 36 inches at Room #420 by an unoccupied Geri Chair
b). approximately 39 inches at Room #414 by an open, unoccupied wheelchair
c). approximately 38 inches at Room #417 by an open, unoccupied wheelchair

4. Observation on 7/11/11 from 2:58 PM until 3:05 PM revealed the Unit Three corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

a). approximately 39 inches at Room #313 by an open unoccupied wheelchair
b). approximately 42 inches at Room #319 by an open, unoccupied wheelchair
c). approximately 39 inches at Room #329 by an open, unoccupied wheelchair

5. Observation on 7/13/11 from 11:25 AM until 11:20 AM revealed the Ground Floor Service corridor is six feet wide. The corridor was observed obstructed to less than four feet (48 inches) in the following location by the following items:

a). approximately 22 inches at the Laundry Room by a mobile soiled linen container and a linen storage rack
b). approximately 37 inches at the Laundry Room by a hanging clothes rack

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 7.1.10

THIS IS REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 6/16/10.

Based on observation during a Life Safety Code survey, smoke barrier walls were not complete from floor to roof deck on two (Unit Two, Unit Four) of three resident units and the Ground Floor. Issues include penetrations through smoke barrier walls. 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 above the ceiling tiles on 7/12/11 at approximately 9:24 AM, in the Ground Floor Ladies Locker Room, revealed an approximate six inch by eighteen inch penetration through the smoke barrier wall. Further observations at this same time revealed nine unsealed seams between sheets of drywall. The unsealed seams were approximately 1/4 inch thick and approximately 36-inches long.

2. Observations above the ceiling tiles on 7/12/11 at approximately 9:36 AM revealed an approximate three inch by three inch penetration through the smoke barrier in the Beauty Salon on Unit Four.

3. Observations above the ceiling tiles on 7/12/11 at approximately 10:10 AM revealed an approximate six foot long section of unsealed corrugated ceiling deck at the Unit Two smoke barrier wall. Each unsealed corrugation was approximately one-inch wide by one half inch high.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.7.3, 8.3.2