Absolut Center for Nursing and Rehabilitation at Houghton, LLC

Based on observation, and staff interview, drugs and biologicals used in the facility were not stored in accordance with State and Federal laws in locked compartments, including a separately locked, permanently affixed compartment for controlled drugs listed in Schedule II. Three (Halls 100 & 400, 200, 300) of three medication carts observed for medication storage had issues involving improper storage of Schedule II drugs in unit medication carts and storage of Schedule III and IV drugs in medication carts that were not rendered immovable when not in use. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation of the medication cart for halls 100 and 400 on 8/31/11 from 8:00 AM to 8:45 AM revealed the cart was unattended, locked and was stored in the hall outside the main dining room. The medication cart was not secured to either the wall or the floor. The locked metal box inside the cart contained Oxycodone (narcotic pain medication - Schedule II controlled substance), Hydrocodone (narcotic pain medication - Schedule III controlled substance), Lorazepam (anti-anxiety/sedative medication - Schedule IV controlled substance), and Clonazepam (sedative/seizure medication - Schedule IV controlled substance). The medication cart for hall 300 was also stored in the hall outside the main dining room at this time. The medication cart was unattended, locked and not secured to either the wall or the floor. The locked, metal box inside the cart contained Morphine (narcotic pain medication - Schedule II controlled substance), Hydrocodone, Lorazepam, and Diazepam (anti anxiety medication - Schedule IV controlled substance). When interviewed at this time the Licensed Practical Nurse (LPN) Medication Nurse revealed that they routinely stored the medication carts in this hall during breakfast.

Observation of the medication cart for hall 300 on 8/31/11 from 3:00 PM to 3:55 PM revealed the cart was stored in the 300 hall. The cart was unattended, locked and was not secured to either the wall or the floor. The locked metal box inside the cart contained Morphine Sulfate (MSO4 - narcotic pain medication - Schedule II controlled substance) When interviewed at this time the medication nurse said that she routinely stores the MSO4 in the medication cart during her shift from approximately 2:00 PM to 10:00 PM.

Additional observation on 8/31/11 from 3:00 PM to 3:55 PM revealed the medication cart for hall 100 was stored in the 100 hall and was unattended, locked and not secured to either the wall or the floor. The locked metal box inside the cart contained Methadone (narcotic pain medication - Schedule II controlled substance) and Oxycodone. Interview with the medication nurse revealed at this time she routinely stored the Methadone and Oxycodone in the medication cart during her shift from approximately 2:00 PM to 10:00 PM.

Observation on 8/31/11 at 4:30 PM revealed the medication cart for hall 200 was stored by the nurse's desk in the 200 hall. The cart was unattended, locked and was not secured to either the wall or the floor. The locked metal box inside the cart contained Hydrocodone and Lorazepam. Interview with the medication nurse at this time revealed she stored the narcotic medications in the cart during the shift from approximately 2:00 PM until 10:00 PM.

Observation on 9/1/11 from 7:50 AM to 9:00 AM revealed two medication carts were stored in the hall outside the Main Dining Room. The carts were unattended, locked and were not secured to either the wall or the floor. The 300 hall cart contained Fentanyl (narcotic pain medication - Schedule II controlled substance) patches and Morphine elixir. The carts were approximately 16 feet away from a door leading to the outside. During this time staff members were observed going in and out of this door for smoking breaks and a delivery truck made a delivery through this door.

415.18(e)(1)(2)

Based on record review and staff interview, the facility did not ensure that a resident with limited range of motion (ROM) receives appropriate treatment and services to increase ROM and/or to prevent a further decrease in ROM. One (Resident #58) of four residents reviewed for range of motion services did not receive ROM as planned and in accordance with Physical and Occupational Therapy recommendations. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #58 has diagnoses that include dementia, osteoarthritis and history of a right (R) below the knee amputation. Review of the Minimum Data Set (MDS) dated 5/19/11 revealed the resident had functional limitations of range of motion (ROM) of both lower extremities.

Review of Physical Therapy (PT) "Rehabilitation Screening" forms dated 2/23/11, 5/17/11, and 8/18/11 revealed the resident had limited joint mobility of the hips, knees, and left (L) ankle.

Review of a PT Consultation Form dated 8/4/11 and the PT Rehabilitation Screening form dated 8/18/11 revealed a nursing recommendation to provide "ROM to BLE (bilateral lower extremities) 3 x/week".

Review of Occupational Therapy (OT) "Rehabilitation Screening" forms dated 2/18/11, 5/17/11 and 8/23/11 revealed the resident had limited joint mobility of the right shoulder. Additional review of the OT Rehabilitation Screening forms revealed nursing recommendations to provide PROM (passive ROM - exercise performed on the resident by nursing staff) to the resident's shoulders and elbows 3 times per week.

Review of the comprehensive Care Plan dated 9/1/11 revealed the resident had "Limited joint range of motion r/t (related to) cognitive impairment" with an approach to provide ROM to both shoulders/ elbows and both LE (lower extremities) 3 x/ week.

Interview with the Director of Rehabilitation and the Occupational Therapist on 8/31/11 at approximately 1:30 PM revealed Resident #58's ROM program is recorded on Restorative Nursing Program sheets located in the CNA (certified nurse aide) ADL (activities of daily living) book, and prior month's sheets are kept in the resident's medical record.

Review of Restorative Nursing Program sheets dated 6/11 through 8/11 revealed the following:

- 6/11 - ROM was attempted/provided 9 times of the 12 planned sessions
- 7/11 - ROM was provided 3 of 12 planned sessions
- 8/11 - ROM was attempted/provided 5 of 12 planned sessions

Additional review of the Restorative Nursing Program sheets revealed no documented evidence that ROM was provided 3x/week as planned.

Interview with the CNA ROM Aide on 8/31/11 at 11:30 AM revealed there is only one ROM Aide in the facility at any given time to provide all of the facility's ROM. The ROM Aide stated that she also assists with the unit ambulation program, so she actually has about 4 hours each day to perform ROM, and she does not get to all of the residents who are to receive ROM.

Interview with the ROM Aide on 9/1/11 at 1:42 PM revealed that Resident #58 can be resistive/combative at times with care and/or ROM services, but she is still able to provide his ROM most of the time. The ROM Aide explained that when the resident is resistive to the point that she is unable to provide ROM, she will document a "R" for refusal. The ROM Aide confirmed that she is unable to provide ROM to Resident #58 the recommended 3 x/week, as she does not have the time, but that she tries to get to him at least once a week. The ROM Aide confirmed that the Registered Nurse (RN) MDS Coordinator supervises the ROM program, and is aware of her (the ROM Aide's) inability to perform all of the ROM assignments.

Interview with the RN MDS Coordinator on 9/1/11 at 1:59 PM confirmed that she is aware that the ROM Aides are not able to complete their ROM assignments related to time constraints. The RN MDS Coordinator stated that she has brought this to the attention of the Director of Nursing (DON) on several occasions and she has recommended that ROM be provided on other shifts. The RN MDS Coordinator stated there has been no change in the staffing or a revision of the way ROM is provided.

Interview with the DON on 9/1/11 at 4:00 PM confirmed that the MDS Coordinator spoke to her regarding ROM services. The DON said it was her impression that ROM services were not performed to all residents only when it was required to pull the CNA ROM Aide and reassign her to resident care.

415.12(e)(2)

Based on record review and staff interview conducted during a complaint investigation (complaint #NY00103652) during the Standard survey completed 9/2/11, the facility did not immediately consult with the resident's physician and notify the resident's legal representative or an interested family member when there was a significant change in the resident's physical, mental, or psychosocial status. One (Resident #26) of four residents reviewed for accidents had an issue with the lack of timely physician and family notification after the resident had a significant change in condition. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #26 has diagnoses including senile dementia, seizure disorder and osteoarthritis. Review of the Minimum Data Set (MDS) dated 6/28/11 revealed the resident has severe cognitive impairment, no speech, never understands, and is never understood.

Review of a Registered Nurse (RN) Nurses Note dated 7/6/11 at 9:50 PM revealed that the certified nurse aide (CNA) was concerned because the resident's right lower leg appeared "floppy". The RN documented that the resident's "leg was warm to touch, wiggling toes, pushing back a little when moving leg, no signs and symptoms of pain, leg and knee are no larger than normal, leg in normal alignment". The note included that the resident had a purple bruise 3.0 centimeters (cm) by (x) 3.5 cm on the right anterior knee, a 13 cm x 6 cm purple bruise on the posterior upper calf and a 1 cm x 0.4 cm abrasion noted on the right posterior upper calf.

Review of an untitled incident report dated 7/6/11 and an RN Nurses Note dated 7/8/11 revealed that the Physician was informed of the bruise on the resident's right leg on 7/8/11 at 9:00 AM and that a message was left with the responsible party regarding the right leg bruises on 7/8/11 at 1:00 PM.

Review of a 24-hour Nursing Services Report dated 7/6/11 revealed no documentation of the bruises and abrasion that were observed at 9:50 PM. Review of a 24-hour Nursing Services Report dated 7/7/11 revealed entries regarding a right knee bruise on the 6:00 AM to 2:00 PM, 2:00 PM to 10:00 PM and 10:00 PM to 6:00 AM shifts.

When interviewed on 9/1/11 at 9:20 AM, the RN Director of Nursing (DON) revealed that she was informed about the bruises on 7/6/11 in the evening via telephone. The DON confirmed that the Physician and the resident's responsible party were notified of the bruises on 7/8/11 and that notification should have occurred on 7/7/11.

415.3(e)(2)(ii)(b)

Based on observation, and staff interview, the facility did not maintain an effective pest control program so that the facility is free of pests. The issue involved the presence of flies in the kitchen during food preparation and service. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. On 8/31/11, during observation of the lunch meal preparation at 10:45 AM and the lunch trayline service from 11:45 AM to 12:50 PM multiple flies were observed in the kitchen. The flies landed on the food preparation table as the puree meal was being prepared, on clean dishes that were being used to serve the lunch meal and on food items in the steam table that were being served to residents. During this observation the cook told a staff member to close a door that led out of the kitchen to a small hallway that led to an exit door. Additionally, a bug light that was affixed to the kitchen wall near the reach-in cooler was on.

When interviewed on 8/31/11 at approximately 11:15 AM the Food Service Director (FSD) stated that the maintenance department cleans out the bug light every 3 to 4 weeks and that the facility has a company that sprays for insects.

When interviewed on 9/2/11 at 9:15 AM the Registered Dietitian said that she hadn't seen that many flies in the kitchen before and that the flies may be coming in through the back door. The RD said that there is a dumpster outside and there is likely to be a lot of flies.

415.29(j)(5)

Based on observation, record review, and staff interview the facility did not ensure that menus were followed to meet the nutritional needs of residents. The issues involved an entree that was not prepared according to the planned recipe and one (Resident #20) of four residents reviewed for nutrition were not provided portion sizes as planned. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy .

The findings are:

1. Review of the facility menu dated 8/31/11 revealed that the main entree for the lunch menu was chicken and dumplings.

Review of the chicken and dumpling recipe revealed instructions to combine chicken base, carrots, celery, and onion, cook until tender, add cooked chicken and simmer. The recipe then instructed to combine biscuit mix and milk, roll out into one half (1/2) inch squares, drop the dough into the chicken mixture and simmer for ten minutes. Further review of the recipe revealed that the serving size for the entree was 1 cup (chicken, sauce and dumplings combined).

On 8/31/11 from 10:45 AM through 12:50 PM the lunch meal trayline service was observed. During this time the cook placed one cup of chicken with sauce over a biscuit square. The chicken and sauce contained no dumplings. By providing 1 cup of chicken with sauce that did not contain dumplings, the portion size provided was actually larger than planned. By the end of the trayline the main entree ran out. For the last 5 residents, the cook gave one resident a half portion of chicken and biscuit, 2 residents the alternate entree choice, and 2 others soup and sandwich.

When interviewed on 8/31/11 at approximately 12:50 PM, the Registered Dietitian (RD) and the Food Service Director verified that they ran out of the main entree before all the residents were served.

When interviewed on 9/2/11 at 9:15 AM the RD said that the cook did not follow the recipe for chicken and dumplings and therefore didn't follow the planned menu. She said that the dumplings should have been in the sauce and included in the one cup serving. The RD also said that the resident who received the half portion did not request or want half a portion.

2. Resident #20 has diagnoses including diabetes mellitus, and senile dementia. Review of the Minimum Data Set (MDS) dated 7/15/11 revealed that the resident has severely impaired cognition.

Review of Physician's Orders dated 8/5/11 revealed an order for a Consistent Carbohydrate Diet (CCD) with No Added Salt (NAS). The orders also included orders for Lantus insulin, weekly and as needed accuchecks (portable device used to test blood glucose levels by using fingerstick blood sample).

Review of the Care Plan for diabetes, dated 8/10/04 revealed that the resident is at risk for unstable blood sugars. Review of the Care Plan for nutrition dated 5/14/02 revealed approaches including a Consistent Carbohydrate Diet (CCD). The Care Plan did not specify a plan for half portions.

Review of the Nutritional Screening/Assessment dated 6/24/11 and Nutritional Progress Notes dated 6/24/11 through 7/20/11 revealed no plan for half portions.

Review of the facility diet manual revealed that the CCD diet was planned to provide 71 to 86 grams of carbohydrates at the lunch meal.

During observation of trayline service on 8/31/11 at approximately 12:45 PM, the cook gave the resident a half portion of the main entree. Review of the resident's meal ticket revealed that the resident was to receive a CCD, NAS diet and there was no indication that the resident was to receive half portions.

When interviewed on 8/31/11 at 12:45 PM the cook said that she gave the resident half portions because she knows that is what the resident likes.

When interviewed on 8/31/11 at approximately 1:15 PM and again on 9/2/11 at 9:15 AM, the RD said she was not aware that the cook gave the resident a half portion and that it was not part of the resident's planned diet. The RD also said that the resident did not want half portions nor did she ever ask for them.

415.14(c)(3)

Based on record review and staff interview, the facility did not ensure that the Pre-Admission Screening and Resident Review (PASRR) was completed as required. One (Resident # 27) of one resident with a diagnosis of mental retardation did not have a Level II screen completed prior to admission. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #27 has diagnoses of depression, bipolar disease, and mild mental retardation. Review of the Minimum Data Set (MDS) dated 7/4/11 revealed the resident is cognitively intact, understands others, and is understood.

Review of the medical record Face Sheet revealed the resident was admitted to the facility on 6/27/11 and re-admitted on 7/12/11.

Review of a Screen Form completed prior to admission dated 6/16/11 revealed the Level I Review did not identify that the resident had a diagnosis or documented history of mental retardation and/or a developmental disability.

Review of Progress Notes, written by the Social Services Director, dated 7/15/11 revealed the resident has a diagnosis of mental retardation and previously lived in an Adult Home.

Review of a Screen Form completed 8/10/11 revealed the Level I Review documented that the resident did have a diagnosis or documented history or mental retardation and/or a developmental disability and that the resident was referred for a Level II evaluation.

Review of the entire medical record revealed no documented evidence that a Level II evaluation was done.

Interview with the Social Worker (SW) on 8/31/11 at 1:30 PM confirmed that a Level II PASRR was not done. The SW stated that she did not realize that a Level II PASRR needed to be done for the resident.

415.11(e)
none

Based on record review and staff interview conducted during a complaint investigation (complaint #NY00103652) during the Standard survey completed 9/2/11, the facility did not provide the necessary care and services to attain or maintain the highest practicable physical, mental, and psychosocial well-being, in accordance with the comprehensive assessment and plan of care. One (Resident #26) of four residents reviewed for accidents did not receive timely follow-up and treatment following a change in condition of a resident's leg. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #26 has diagnoses of senile dementia, seizure disorder and osteoarthritis. Review of the Minimum Data Set (MDS) dated 6/28/11 revealed the resident has severe cognitive impairment, never understands, and is never understood, with no speech. Additional review of the MDS revealed the staff assessment for pain indicated the resident received scheduled pain medications and had no non-verbal sounds, no vocal complaints of pain, no facial expressions, and no protective body movements or postures.

Review of the comprehensive Care Plan (CCP) dated 6/9/11 revealed the resident has senile dementia, is unable to make her needs known, and is non-communicative and non-responsive to the environment. Additional review of the Care Plan revealed the resident has the potential for altered comfort related to osteoarthritis, spinal stenosis (narrowing of one or more areas in the spine), contractures (loss of joint mobility), and a history of a left forearm fracture. Care Plan approaches included plans to:

- observe the resident for expressions of pain
- report any pain or discomfort with ROM (range of motion)
- monitor facial grimaces and stiffening of neck and extremities
- monitor the resident for pain
- update the physician and family with any change
- medicate with oral Lortab (narcotic pain medication) twice a day and every four hours as needed (PRN).

Review of Physician's Orders dated 5/16/11 revealed an order for Hyrdrocodone Acetaminophen (Lortab) 5/500 milligrams (mg) one tablet by mouth twice daily for pain and every 4 hours as needed for a pain scale of "4 - 5" (the assessment of pain using a scale from "0" to "10").

Review of Medication Administration Records (MARs) dated 6/11 and 7/1/11 to 7/10/11 revealed the resident received Lortab 5/500 mg twice daily at 5:00 AM and 3:00 PM.

Review of a Nurses Note, written by the Registered Nurse (RN) Evening Supervisor (RN #2) dated 7/6/11 at 9:50 PM revealed a certified nurse aide (CNA #1) was concerned because the resident's right lower leg appeared "floppy". The RN documented that the resident's leg was warm to touch and she was wriggling her toes and pushing back a little when the right leg was moved. There were no signs and symptoms of pain, the right leg and knee were no larger than normal and the leg was in normal alignment. The RN also documented that there was a 3.0 centimeter (cm) by (x) 3.5 cm purple bruise on the right anterior (front of) knee, a 13.0 cm x 6.0 cm purple bruise on the right posterior (back of), upper calf and a 1.0 cm x 0.4 cm abrasion on the right posterior upper calf.

Interview with CNA #1 who initially reported the bruise on 7/6/11 on 8/31/11 at 4:31 PM revealed that she noticed a bruise underneath the resident's leg on 7/5/11. The next day CNA #1 and CNA #2 rolled the resident during care and noted that her leg "flopped, which was unusual". CNA #1 said that she informed the nurse (RN #1) that there was something wrong with the resident's leg. CNA #1 stated that she noticed another bruise later that night. RN #1 wasn't around so she got the RN Supervisor (RN #2) between 9:00 PM and 9:30 PM, who then checked the resident. CNA #1 said she thought the resident was in pain because she made facial expressions, specifically, she squinted a little bit, which she reported to the nurse. CNA #1 explained that the resident does not express her needs verbally; staff always have to anticipate her needs. CNA #1 stated that she has taken care of Resident #26 for 6 years and this was a big difference. The CNA stated that Resident #26 did not really make any facial expressions except when she was in pain.

Interview with RN #1 on 8/31/11 at 4:45 PM revealed she did not notice that Resident #26's leg was floppy and she did not check the other leg because CNA #1 did not ask her to check it. RN #1 did not document her assessment in the Nurses' Notes for Resident #26.

Interview with the RN Evening Nursing Supervisor (RN #2) on 8/31/11 at 4:50 PM revealed Wednesday (7/6/11) was the first day that CNA #1 told her that the resident had bruising on her right knee and that her leg was floppy. RN #2 stated that when she checked the resident she had no signs and symptoms of pain and she was able to do full ROM (knee to chest) which was normal for the resident.

A Nurses Note written by the RN Day Supervisor (RN #3) dated 7/8/11 at 9:00 AM revealed that Physician #1 (on call physician) was notified of the bruise on the resident's right leg and a message was left with the resident's responsible party at 1:00 PM.

Interview with the RN Day Nursing Supervisor (RN #3) on 9/1/11 at 9:45 AM revealed she went to look at the resident's bruise the morning of 7/8/11. The CNAs had already transferred the resident into a chair so she raised the resident's pant leg to above her knee and visualized the bruises on the knee. The RN stated she notified the Physician on-call about the bruise and informed him that the resident had no pain. The RN Day Supervisor stated that the on-call Physician (Physician #1) did not know the resident and she did not provide any resident history when she reported the bruise. During the interview, the RN stated she knew the resident had a history of a fractured left arm and seizure disorder, however, she did not relay this history to the on-call physician. The RN stated she did not request an x-ray when she talked to the physician on 7/8/11 because there was no swelling or any indication the resident had pain when she assessed her.

Additional review of Nurses' Notes revealed the following:

- On 7/9/11 at 11:30 AM, a Licensed Practical Nurse (LPN #1) documented that the resident's right knee was bigger than the left knee and pain was noted with passive range of motion (ROM).
- On 7/9/11 for the 2:00 PM to 10:00 PM shift, an RN (#4) documented that the swelling was worsening on the right leg, the thigh was yellow and the skin was taut with a small bruise noted on the right groin.
- On 7/10/11 at 4:40 AM, RN #2 documented that the resident's right leg was swollen, there was bruising on the groin and upper thigh, and a yellow skin discoloration with pain on PROM on the right hip.
- On 7/10/11 at 9:30 AM, a phone call was placed to Physician #2 and "stat" (immediate) x-rays of the right hip, knee and thigh were ordered at 10:20 AM.
- On 7/10/11 at 1:15 PM, RN #5 documented that the x-rays were obtained and at 3:30 PM, radiology reported the results of the x-rays to the facility.

Review of the Right Knee and Right Femur X-ray Reports dated 7/10/11 revealed the resident had a mid to distal (lower portion) right femoral shaft fracture which was comminuted (broken or crushed into small pieces) and displaced.

Additional review of the 7/11 MAR revealed PRN Lortab was not administered on 7/9/11 and given once on 7/10/11 at 10:00 AM for "s/s (signs and symptoms) of pain (moaning, facial grimacing).

Review of Nurses' Notes written by an RN on 7/10/11 at 4:50 PM revealed the resident was transferred to the hospital for treatment of the right leg fracture.

none Interview with the DON on 9/1/11 at 9:20 AM revealed she was informed about the bruise via telephone the evening of 7/9/11 and it was on the morning report. The DON stated she did not know why the Physician and the responsible party were not notified on 7/7/11 regarding the resident's bruises. The RN Day Supervisor notified Physician #1 (on call physician) and the family on the morning of the 7/8/11. The DON stated she looked at the resident's leg herself that morning and she told the Day Nursing Supervisor to inform Physician #1 and the responsible party.

Interview with an LPN Day Shift Nurse (LPN #1) on 9/2/11 at approximately 11:00 AM revealed on 7/9/11 she noticed that the resident was wincing with range of motion (ROM) but it stopped when she wasn't moved; she thought it was because of her arthritis, and staff already knew she had the bruising. In addition, the CNAs did not report any wincing with care.

Additional interview with the DON on 9/1/11 at approximately 11:00 AM revealed the nurses should provide pertinent resident history when calling a Physician, including information for the purpose for the call. When she evaluated the resident on 7/8/11, she was not aware the resident had a history of an old fracture; however, by 7/10/11 she was aware and believed it was significant. The DON stated if she knew the resident had a history of osteoarthritis and an old fracture, she would have asked the physician for an x-ray.

In summary, a certified nurse aide observed a bruise on Resident #26's right leg on 7/5/11. The right leg was observed to be bruised and "floppy" on 7/6/11. Pain was noted during ROM on 7/9/11 and right leg swelling increased. Bruising progressed and pain continued on 7/10/11. X-rays were ordered on 7/10/11 which showed a displaced fracture of the distal right femur. The resident was transferred to the hospital for treatment on 7/10/11. There was a lack of timely treatment of the resident's right leg fracture. Resident #26 was not able to communicate and make her needs known.

415.12
none

Based on observation and staff interview during a Life Safety Code survey, corridor walls were not constructed to resist the passage of smoke. This affected one (Main Street Unit) of five resident use units. 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 8/30/11 at approximately 11:15 AM revealed an approximate two inch long by two inch wide open, unsealed area in the Main Street Unit corridor wall. Also at this time observation revealed that this open, unsealed penetration went directly through the wall that separates the Main Street Unit corridor from the Laundry room. Further observation at this time revealed that the Main Street Unit corridor was not sprinklered, that the Laundry room was sprinklered and that both of these areas had a ceiling designed of lay-in style ceiling tiles. Continued observation at this time revealed that this open, unsealed penetration was located in the Main Street Unit corridor wall above the door to the Laundry room that was located across from the Physical Therapy room.

2. Observation above the ceiling tiles on 8/30/11 at approximately 11:18 AM revealed an approximate three inch long by three inch wide open, unsealed area in the Main Street Unit corridor wall. Also at this time observation revealed that this open, unsealed penetration went directly through the wall that separates the Main Street Unit corridor from the Laundry room. Further observation at this time revealed that the Main Street Unit corridor was not sprinklered, that the Laundry room was sprinklered and that both of these areas had a ceiling designed of lay-in style ceiling tiles. Continued observation at this time revealed that this open, unsealed penetration was located in the Main Street Unit corridor wall near the door to the Laundry room that was located across from the Basement.

Interview with the Corporate Plant Operations Manager on 8/30/11 at approximately 1:03 PM revealed that the open, unsealed penetrations in the Main Street Unit corridor wall probably go back to the original construction of the building and that he was not aware of any current work being done on the corridor walls in these areas.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 19.3.6.1, 19.3.6.2.2

Based on observation and staff interview during a Life Safety Code survey, smoke barrier walls were not complete from floor to roof deck. This affected four (100, 200, 300, Main Street Unit) of five resident use units. 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:

1. Observation above the ceiling tiles on the 200 Unit on 8/30/11 at approximately 9:48 AM revealed an approximate three inch long by one quarter inch wide open, unsealed penetration below a ventilation duct that ran through the 200 Unit smoke barrier wall. Further observation at this time revealed that this open, unsealed penetration was located above the smoke barrier doors on the 200 Unit near the Activities/Lounge room.

Observation above the ceiling tiles on the 200 Unit on 8/30/11 at approximately 9:56 AM revealed an approximate three inch long by one quarter inch to one half inch wide open, unsealed penetration above a ventilation duct in the 200 Unit smoke barrier wall. Further observation at this time revealed that this open, unsealed penetration was located above the smoke barrier doors on the 200 Unit near the Clean Utility room.

2. Observation above the ceiling tiles on the 300 Unit on 8/30/11 at approximately 10:11 AM revealed an approximate three inch long by one quarter inch to one half inch wide open, unsealed penetration above a ventilation duct in the 300 Unit smoke barrier wall. Further observation at this time revealed that this open, unsealed penetration was located above the smoke barrier doors on the 300 Unit near the Shower room.

Observation above the ceiling tiles on the 300 Unit on 8/30/11 at approximately 10:17 AM revealed two ventilation ducts that ran through the 300 Unit smoke barrier wall each had an approximate 14 inch long by one half inch wide open, unsealed penetration above them. Further observation at this time revealed that these open, unsealed penetrations were located above the smoke barrier doors on the 300 Unit near resident rooms #301 and #302.

3. Observation above the ceiling tiles of the Main Street Unit on 8/30/11 at approximately 10:25 AM revealed an approximate three inch long by one half inch wide open, unsealed penetration above a ventilation duct that ran through the Main Street Unit smoke barrier wall. Also at this time observation above the ceiling tiles on the Main Street Unit revealed an approximate one inch long by one half inch wide open, unsealed area around a conduit that ran through the Main Street Unit smoke barrier wall. Further observation at this time revealed that these open, unsealed penetrations were located above the smoke barrier doors on the Main Street Unit near the Medication room.

4. Observation above the ceiling tiles on the 100 Unit on 8/30/11 at approximately 10:35 AM revealed an approximate 14 inch long by one half inch wide open, unsealed penetration above a ventilation duct that ran through the 100 Unit smoke barrier wall. Also at this time an approximate two inch long by two inch wide open, unsealed area of the 100 Unit smoke barrier wall lacked gypsum board. Further observation at this time revealed that these open, unsealed penetrations were located above the 100 Unit smoke barrier doors near resident room #101.

Interview with the Corporate Plant Operations Manager on 8/30/11 at approximately 1:01 PM revealed that he was not aware of the open, unsealed penetrations in the smoke barrier walls and that the open, unsealed penetrations were probably due to deterioration in the smoke barrier walls.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.3.7.3, 8.3, 8.3.2