Avalon Gardens Rehabilitation & Health Care Center, Inc

Based on record review and staff interviews during the recertification survey, the facility did not develop or revise a Comprehensive Care Plan based upon behavior and assessments for one of thirty sampled residents. Specifically, Resident #9 exhibited elopement attempts from the facility's locked Behavioral Unit on 5/13/10, 7/11/10, and 7/16/10 and had a history of using and removing a wanderguard. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #9 has diagnoses including Chronic Paranoid Schizophrenia and Impulse Control Disorder.

The Minimum Data Set (MDS) assessment completed 4/19/10 documented the resident's Cognitive Skills For Daily Decision Making as "Moderately Impaired - decisions poor, cues/supervision required", and with impaired memory.

A 7/20/10 review of the resident's Interdisciplinary Progress Notes dated 5/13/10, 7/11/10, and 7/16/10 revealed attempts to exit the locked unit without authorization.

The Director of the locked Behavioral Unit where the resident resided was interviewed on 7/20/10 at 8:55 AM and stated that she was aware of the resident's elopement attempts, and reviewing the resident's current CCP with the surveyor at that time, she stated there was no documented evidence that a CCP had been developed for either the above mentioned elopement attempts or the resident's use of a wanderguard, and she was not certain if as per facility policy, one should have been developed. The Director also stated that the most current Elopement Risk Assessment for the resident in his clinical record, dated 10/15/09 and documented as a "Low Risk", was no longer accurate based upon the resident's recent behavior.

The locked Behavioral Unit Licensed Practical Nurse (LPN) Medication Nurse was interviewed on 7/20/10 at 8:50 AM and stated that Resident #9 had recently refused to wear a wanderguard, but staff had spoken with the resident and encouraged him to wear one, which he currently does and is checked for compliance with each shift.

A Registered Nurse (RN) Nursing Supervisor was interviewed on 7/20/10 at 10:24 AM and on 7/21/10 at 8:05 AM and stated that he found a CCP created for the resident's 5/13/10 elopement attempt in a "to be filed" folder on the unit that was dated 5/13/10 and said that it should have been in the resident's chart. That CCP was most recently updated 7/6/10 with documentation that the resident had made no further elopement attempts. There was no documentation on that CCP identifying the resident as either wearing a wanderguard or his behavior of removing it. The RN also stated that the resident's Elopement Risk Assessment should have been updated quarterly since last done 10/15/09, but he could not find such documentation, and that if he found it, it would be brought to the surveyor's attention (the document was never provided). The RN also stated that CCPs are not updated more than every week or ten days and that was why the elopement attempts of 7/11/10 and 7/16/10 were not documented on the resident's Elopement CCP.

The Interdisciplinary Progress Notes dated 6/7/10 and 6/15/10 documented that the resident had removed his wanderguard and was not wearing one for those eight days.

The Director of Nursing (DON) was interviewed on 7/20/10 at 8:55 AM and 10:10 AM and on 7/21/10 at 10:25 AM regarding Resident #9 who resided on the locked Behavioral Unit. The DON stated that if the resident had made any attempts at elopement, those attempts should have been documented on either an Elopement or Behavior CCP in the resident's chart. The DON further stated that the use of and the behavior of removing the wanderguard should also have been documented as part of that CCP.

415.11(c)(1)

Based on observation, record review, and staff interviews during the recertification survey, the facility did not ensure that one out of sample resident in a total sample of thirty had privacy. Specifically, Resident #38 was observed lying in bed with her brief and left thigh exposed, in full view of staff and other residents as they passed the room. The privacy curtain was not closed around the resident's bed and the door to the hallway was open. This resulted in no actual harm with the potential of more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #38 has diagnoses which include Dementia.

The Minimum Data Set (MDS) assessment dated 5/26/10 documented that the resident had modified independence in cognitive skills for daily decision-making and was totally dependent on two persons for bed mobility.

On 7/21/10 at 6:45 AM, the resident was observed lying in bed on her back with her bed curtain open. The resident's left thigh and brief were exposed and the resident could be seen from the hallway.

An interview was held on 7/21/10 at 8:45 AM with the resident's CNA (Certified Nursing Assistant) #1. CNA #1 stated that she should have closed the resident's bed curtain.

An interview was held on 7/21/10 at 8:50 AM with CNA #2 who had passed the resident's bed. CNA #2 stated that she did not realize that the resident was uncovered. CNA #2 also stated that the resident was not assigned to her.

A Physical Therapist (PT) who had also passed the resident's doorway was interviewed on 7/21/10 at 8:55 AM and stated that the resident's privacy curtain should have been closed.

The Director of Nursing (DON) was interviewed on 7/21/10 at 9:00 AM and stated that the resident should have been covered.

415.5(a)

Based on interviews and record review during the recertification survey, the facility did not ensure that the the facility's established infection control program was followed to help prevent the development and transmission of disease and infection. This was evident for one of 30 sampled residents. Specifically, Resident #10 was admitted to the facility on 1/5/10, with no documented evidence that a PPD (a test for tuberculoses) was offered and administered. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #10 was admitted to the facility on 1/5/10 and had diagnoses including Diabetes Mellitus and Peripheral Vascular Disease.

The Social Work Progress Notes documented that the resident had resided in a nursing home prior to being hospitalized and then admitted to this nursing home.

A review of the resident's medical record including the immunization record, Physician's Orders, Nursing Progress Notes, and Comprehensive Care Plans revealed no documented evidence that a PPD was offered and/or administered to the resident.

The unit Registered Nurse (RN) Charge Nurse was interviewed on 7/16/10 at 1:00 PM and stated that the resident may have refused the test. The RN also stated that if the resident refused to take the PPD test, he should have been educated by the Nurses, Social Worker, and Physician to take it. If the resident continued to refuse, then a chest X-ray should have been obtained.

415.19(a)(1-3)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that laboratory services were performed timely for two of thirty sampled residents. (Resident #25 and #20) Specifically, Resident #25 had laboratory tests ordered which were performed five days after the Physician ordered them and Resident #20 had stool specimens ordered to assess for Clostridium Difficile (C-Diff) toxin which were never performed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #25 has diagnoses including Viral Hepatitis and Cirrhosis of the Liver.

The Physician's Orders dated 7/12/10 documented the following tests to be completed on 7/15/10 for Anemia: Complete Blood Count, Iron, Total Iron Binding Capacity, Ferritin, Vitamin B12, Folic Acid and Stool for Guiac (microscopic blood) x two.

A review of the record on 7/20/10 at 12:00 PM revealed no documented evidence of the reports for the tests ordered for 7/15/10.

The unit Registered Nurse (RN) Charge Nurse was interviewed on 7/21/10 at 9:00 AM and stated that according to the Laboratory Accessioning Sheet, the blood sample had been drawn on 7/15/10. The RN stated that the report was obtained on 7/20/10 at 4:00 PM which documented that the sample had been collected on 7/15/10 at 8:45 AM, received on 7/15/10 at 2:21 PM, and the result reported on 7/20/10 at 3:48 PM. The RN also stated that no Stool for Guiac samples had been obtained to send to the laboratory. The RN added that she had attempted to obtain a Stool for Guiac sample on 7/20/10 in the afternoon and the resident had declined.

The Laboratory Manager (LM) was interviewed on 7/21/10 at 9:05 AM and stated that the facility should have received the results of the tests on the day the specimen was obtained or definitely by the next day. The LM then stated that the Laboratory Field Supervisor had spoken with the Technician, who stated that the tests had been entered in the computer on 7/15/10, but the sample had not been drawn until 7/20/10. The Laboratory Manager stated that he could not explain why the Technician had documented in the computer that the sample was obtained on 7/15/10, when it had been obtained on 7/20/10. The LM stated that the Technician was probably having trouble with the resident in obtaining the samples. The LM further stated that the Technician should have communicated with the unit staff regarding the delay and the reasons for it.

The unit RN Charge Nurse was interviewed on 7/21/10 at 10:00 AM regarding the Stool for Guiac test which was still pending and stated that the staff reported that the resident had been declining the Stool for Guiac test. The RN stated that she was not aware that the Technician had not obtained the blood samples and that the Nurses had not obtained the Stool for Guiac samples timely.

The Medical Director was interviewed on 7/21/10 at 12:00 PM and stated that if the staff was unable to follow the Physician's Orders timely, the Physician should be notified.

2) Resident #20 has diagnoses including Morbid Obesity and Depression.

The admission Minimum Data Set (MDS) assessment dated 6/03/10 documented that Resident #20 had no problems with short or long-term memory and was independent regarding daily decision-making skills. Resident #20 was continent of both bowel and bladder, independent regarding transfers, ambulation and toileting use.

A Physician's Progress Note dated 6/16/10 documented that the resident complained of diarrhea for two days and was having small bowel movements along with mild right upper quadrant tenderness.

A Physician's Order dated 6/16/10 documented to obtain two stool specimens to assess for C-Diff and a liver sonogram due to right upper quadrant pain.

Review of the resident's medical record on 7/21/10 at 10:15 AM with the Registered Nurse (RN) Unit Manager present revealed no laboratory results regarding stool specimens.

The Assistant Director of Nursing (ADON) was interviewed on 7/21/10 at 10:15 AM and stated that the laboratory was called and had no record of receiving stool specimens and therefore had no results of stool specimen testing for C-Diff. The ADNS stated that when an order is obtained for stool specimen testing, the Certified Nursing Assistants (CNAs) are informed of the need for a stool specimen collection. The CNA then tells the Nurse that the specimen has been collected, the Nurse completes a laboratory slip and then the specimen and laboratory slip are placed in the nursing office refrigerator for pick up from the laboratory (lab). The lab technician signs the lab slip, takes one copy of the lab slip with the specimen, and leaves one copy of the lab slip at the facility. The facility did not have a copy of lab slips for either stool specimens.

The Director of Nursing (DON) was interviewed on 7/21/10 at 1:50 PM and stated that the resident was alert and would have told the staff when a bowel movement occurred. The DON stated that currently there was no tracking mechanism in place to monitor the timeliness of laboratory services.

A subsequent interview was held with the DON on 7/21/10 at 2:20 PM. The DON stated that the 7 AM-3 PM Licensed Practical Nurse (LPN), who picked up the 6/16/10 Physician's Order for stool specimen collections, documented the need for the stool collection on the twenty-four hour nursing report, however the 3 PM-11 PM LPN dropped the need for the stool specimen collection on the twenty-four hour report. The DNS further stated that the 3 PM-11 PM LPN was no longer employed by the facility.

415.20

Based on record review and staff interviews during the recertification survey, the facility did not ensure that one of thirty sampled residents had a Physician ordered x-ray performed timely. Specifically, Resident #19 had a Physician's Order dated 5/05/10 for a repeat abdominal x -ray to be performed in one week which was not done. This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident # 19 has diagnoses including Dementia and Anemia.

The quarterly Minimum Data Set (MDS) assessment dated 4/12/10 documented that Resident #19 had both short and long-term memory problems, was continent of bowel and bladder, and required supervision/set up of one person for toileting.

A Nurse's Note dated 5/05/10 documented that the resident was complaining of a "belly ache". The Physician was contacted on 5/05/10 and ordered an abdominal x-ray.

The 5/05/10 abdominal x-ray revealed moderate fecal retention and a nonspecific bowel distention. The Physician was contacted and a Physician's Order dated 5/05/10 documented to give Colace 200 milligrams (mg) by mouth at bedtime, Milk of Magnesia 30 cubic centimeters (cc) by mouth at bedtime and to repeat an abdominal x-ray in one week.

Review of the x-ray results with the Registered Nurse (RN) Unit Manager on 7/21/10 at 1:15 PM revealed no x-ray report of the abdominal x-ray ordered on 5/05/10 which was to be performed in one week. The RN contacted the x-ray company and was informed that no abdominal x-ray was performed as ordered.

The Director of Nursing (DON) was interviewed on 7/21/10 at 1:45 PM and stated that the abdominal x-ray should have been performed as ordered by the Physician.

A subsequent interview was held on 7/21/10 at 2:22 PM with the DON. The DON stated that the 3 PM-11 PM Licensed Practical Nurse (LPN) who picked up the Physician's Order on 5/05/10 should have placed a note on the nurse's unit calendar as a reminder to call for an abdominal x-ray in one week (on 5/12/10). The DON reviewed the nurse's unit calendar and stated that that no entry was written (on 5/12/10) to order an abdominal x-ray.

415.21

Based on staff and resident interviews and record reviews during the recertification survey, the facility did not ensure that all resident injuries were thoroughly investigated to prevent potential abuse. This was observed for one resident in a total sample of thirty residents. Specifically, 1) there was no documented evidence that the facility investigated a left forearm skin tear sustained by Resident #5. In addition, 2) 1 of 5 new Certified Nursing Assistants (CNAs) hired in the last 3 months was not thoroughly screened prior to working in the facility. This resulted in no actual harm with a potential for more than minimal harm which is not immediate jeopardy.

The finding is:

1) Resident #5 has diagnoses including Quadriplegia and Seizure Disorder.

The Minimum Data Set (MDS) assessment dated 4/29/10 documented that the resident had intact cognition and memory.

The Integrated Progress Note (IPN) dated 4/3/10 at 3:00 PM documented a left forearm 3/4 inch skin tear to be treated with normal saline and bacitracin daily until the wound healed.

The Treatment Administration Record (TAR) documented that the treatment was administered to the left forearm skin abrasion from 4/3/10 to 4/5/10.

There was no documented evidence in a) the resident's medical record and b) the facility's incident investigation reports for April 2010 that the incident causing the resident's left forearm skin tear/abrasion had been investigated. Additionally there were no specific interventions documented on the Safety Comprehensive Care Plan to prevent a similar occurrence.

The resident was interviewed on 7/18/10 at 11:00 AM regarding the left forearm skin tear. The resident stated that at that time no one knew what caused the injury. The resident further stated that it occurred to him after a few days that his arm probably laid on his lap top computer for a long time and the heat from the computer had caused the burn/abrasion mark.

The Registered Nurse (RN) Charge Nurse was interviewed on 7/18/10 at 12:00 PM and could not explain why the incident had not been investigated.

2) Review of a list of CNAs hired within the last 3 months revealed that 1 of 5 CNAs was not screened timely. The Nurse Aide Registry verification was received on 7/7/10. The CNA was hired on 6/25/10 and assigned to direct resident care prior to the facility receiving the appropriate verification from the registry.

The Director of Human Resources was interviewed on 7/21/10 at 2:00 PM and stated that the CNA should not have been permitted to work in direct resident contact until the registry verification had been received. The Director further stated that the CNA was from an agency and the facility should have checked the report.

415.4(b)(2)

Based on record review, staff interviews, and Facility policy review during the recertification survey, the facility did not ensure that the Preadmission Screening and Resident Review (PASRR) process was completed as required for one of thirty sampled residents reviewed for the PASRR in a total sample of thirty. Specifically, for Resident #9, who was initially admitted to the facility with a psychiatric diagnosis on 12/15/09 and readmitted following a psychiatric hospitalization on 2/10/10, the PASRR process was not formally commenced until 7/21/10 when the omission was brought to the attention of Resident #9's Social Worker. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #9 has diagnoses including Chronic Paranoid Schizophrenia and Poor Impulse Control.

The resident's five last Minimum Data Set (MDS) assessments (dated 1/21/10, 2/19/10, 2/23/10, 3/10/10, and most currently 4/19/10) documented his "Cognitive Skills for Daily Decision Making as Moderately Impaired - decisions poor and cues/supervision required".

The Director of the locked Behavioral Unit where the resident resided was interviewed on 7/20/10 at 8:55 AM at which time she also reviewed the resident's clinical record with the surveyor. The Director was not familiar with what a PASRR was, and once it was explained to her, she could not find the required documents in the resident's clinical record. The Director stated that it was possible that Resident #9's Social Worker had it.

Resident #9's Social Worker was interviewed on 7/21/10 at 9:40 AM and stated that based upon the surveyor's concern, the PASRR process for the resident was just now initiated by the facility, but it should have been commenced at the time of the resident's admission.

The Director of Nursing (DON) was interviewed on 7/21/10 at 10:25 AM and stated she was aware that the facility had a problem regarding PASRRs being completed and that the facility was currently working on that problem.

The facility's policy most recently updated 10/26/07 was reviewed. It did not address the new PASRR requirements that went into effect 11/12/09.

415.11(e)

Based on observations and record review during the recertification survey, the facility did not ensure that safe medication storage conditions including proper temperature, light, or humidity were maintained in accordance with manufacturer's specifications, State requirements and standards of practice (e.g., United States Pharmacopeia (USP) standards). This was noted for the medication refrigerator on one resident unit (Spring) out of a total of seven resident units. Specifically the refrigerator temperature on the Spring Unit was noted to be 32 degrees Fahrenheit (F). Several currently used medications were stored in this refrigerator although the manufacturer's storage instructions recommended storing in temperatures between 36-46 degrees F. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During the initial tour of the Spring unit on 7/16/10 at 9:45 AM, the refrigerator temperature was noted to be at 32 degrees F. The following medications were observed to be stored in the refrigerator: Novolin N 10 milliliter (ml) vials x 2, Novolin R 10 ml vial, Lantus Insulin 10 ml vial, Vancomycin liquid 5.25 ounce bottle, Syprine 250 milligram (mg) 84 capsules. The manufacturer's instructions stated to store these medications between 36-46 degrees F.

The unit Registered Nurse (RN) Charge Nurse was interviewed on 7/16/10 at 10:00 AM and stated that the refrigerator temperature was recorded this morning at 36 degrees F and that it should be maintained between 36-42 degrees F.

415.18(d)

Based on observation and staff interview, the facility did not ensure that the resident call bell system was fully functional in that 1) call bells did not activate a visual signal in the soiled utility room and pantry on the Broadway unit; and 2) the call bell in the training toilet room on the Carnation unit did not work when tested. This was noted on two of seven units.

This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 7/16/10 between 8:30am- 2:00pm during the recertification survey, the resident call bell system was not fully functional. Examples are:

1) Call bells did not activate a visual signal in the soiled utility room and pantry on the Broadway unit.

2) The call bell in the training toilet room on the Carnation unit did not work when tested.

In an interview on 7/16/10 at approximately 11:30am, the maintenance worker stated that he would have the call bell system fixed immediately.

10NYCRR 415.29
10NYCRR 713-1.19(g)(1)

Based on observation and staff interview, the facility did not ensure that housekeeping and maintenance services provided a sanitary, orderly, and comfortable interior. Reference is made to the following:

1. Dirty exhaust grilles on 6 of 7 units.
2. Resident washing machines on 1 of 7 units were not maintained in good repair.
3. A common shower room on 1 of 7 units was not maintained in good repair.

This resulted in no actual harm with potential for minimal harm.

The findings are:

Environmental inspections during the recertification survey on 7/16/10 between 8:45am and 3:00pm revealed the following:

1. The exhaust grilles on 6 of 7 units were observed with an accumulation of a dark brown substance on parts of their exterior and interior surfaces. Examples include but are not limited to the following areas:

- 1 in the corridor and in the common bathroom of the Azalea unit
- 1 in the corridor of the Diamond Unit
- 1 in front of the Rehabilitation department on the Spring Unit
- 1 in the corridor of Emerald Unit
- 1 in the corridor of the Broadway Unit
- 1 in the corridor of the Emerald unit.

In an interview at approximately 11:30am the Director of Environmental Services stated that the grilles are cleaned as scheduled and that the frequency of cleaning would need to be increased. He immediately contacted a housekeeping employee to start cleaning the exhaust grilles.

2. Six residents' washing machines that were located on the Spring Unit were observed missing door handles.

3. The resident common shower room that is located on the Diamond Unit across room D8 was noted with stagnant air. The room was also noted to be musty.

In interviews on the same day, the Director of environmental Services stated that the handles would be replaced on the washing machines and that the exhaust fan for the common shower room needs to be checked.

NYCRR 415.5(h)(2)
415.29

2000 NFPA 101- 19.3.6.4 Transfer Grilles.
Transfer grilles, regardless of whether they are protected by fusible link-operated dampers, shall not be used in these walls or doors.

Based on observation and staff interview, doors protecting corridor openings were not maintained to resist the passage of smoke in that 1) transfer grilles were located at the base of doors to the oxygen storage rooms in the basement and the Spring unit; and 2) doors did not positively latch when tested; examples include but are not limited to the basement porter's closet across from the staff cafeteria and one of the double doors to the Azalea Courtyard Caf was loose on the hinges and catching the floor preventing it from closing.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 7/16/10 between 8:30am- 2:00pm during the recertification survey, the following was noted:

1) Transfer grilles were noted at the base of doors to the oxygen storage rooms in the basement and on the Spring unit.
2) Doors did not positively latch when tested. Examples include but are not limited to:
a. The basement porter's closet across from the staff cafeteria.
b. One of the double doors to the Azalea Courtyard Caf was loose on the hinges and catching the floor preventing it from closing.

In an interview on 7/16/10 at approximately 10:45am, the maintenance worker stated that he will seal the transfer grilles and fix the doors immediately.

711.2(a)(1)

Based on observations and staff interviews, the facility did not ensure that exit access is readily accessible at all times. Reference is made to the following:

1. An exterior egress path (walkway) that was interrupted by a gate that swings against the direction of egress.
2. Water accumulation in portions of an egress corridor.
3. A rusty exit door with a rusty door frame that was difficult to open.

none
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Life Safety inspections during the recertification survey on 7/16/10 between 8:45am and 3:00pm and on 7/19/10 between 8:30am and 1:00pm revealed the following:

1. On 7/19/10, at approximately 12:25pm it was observed that the exterior egress path (walkway) that is located at the back of the D-unit was interrupted by a gate that swings against the direction of egress. In an interview at this time, a maintenance employee stated the gate is one of two gates that serve the enclosed patio. He stated that the gates are alarmed but not locked. In a separate interview at this time the Director of Environmental Services stated that the area might need an additional paved walkway and that the issue would be discussed with the Administrator.

2. On 7/16/10 at approximately 9:45am the basement exit corridor in the vicinity of the Adult Day Health Care Program was observed with water accumulation on parts of the floor surface. In an interview at this time the Director of Environmental Services stated that water is originating from the condensate of the Air Conditioning (A/C) unit that is located in the nearby storage room. He further stated that the drainage for the A/C condensate needs to be redirected to the outside and immediately contacted a housekeeping employee to remove the water from the corridor.

3. On 7/16/10 at approximately 9:00am the basement emergency exit door in the vicinity of the laundry department required extra effort to open when tested. Portions of the door and door frame were observed with rust. In an interview at this time a maintenance employee stated that the door and door frame would be fixed or replaced.

NYCRR 711.2(a)(1)
10 NYCRR 415.29

2000 NFPA 101 Chapter 19.2.10 Marking of Means of Egress. Chapter 19.2.10.1- Means of egress shall have signs in accordance with Section 7.10.

2000 NFPA 101 Chapter 7.10.1.2 - Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

2000 NFPA 101 Chapter 7.10.1.4 Exit Access. Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach the exit is not readily apparent to the occupants. Sign placement shall be such that no point in an exit access corridor is in excess of 100 ft (30 m) from the nearest externally illuminated sign and is not in excess of the marked rating for internally illuminated signs.
Exception: Signs in exit access corridors in existing buildings shall not be required to meet the placement distance requirements.

2000 NFPA 101 Chapter 7.10.2 Directional Signs. A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

2000 NFPA 101 Chapter 7.10.5.1* General.
Every sign required by 7.10.1.2 or 7.10.1.4, other than where operations or processes require low lighting levels, shall be suitably illuminated by a reliable light source. Externally and internally illuminated signs shall be legible in both the normal and emergency lighting mode.

Based on observation and staff interview, 11 emergency exit signs throughout the facility were observed not working and not illuminated.

This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 7/16/10 between 8:30am- 2:00pm during the recertification survey, 11 emergency exit signs throughout the facility were observed not working and not illuminated. Examples of the areas include the basement, Azalea, Carnation, Spring, Broadway and the main entrance.

In an interview on 7/16/10 at approximately 12:30pm, the maintenance worker stated that he would have the exit signs fixed immediately.

711.2(a)(1)

Based on observation, staff interview and record review, the facility did not ensure that fire drills are conducted at least quarterly on each shift and that staff familiarity with the procedures is documented.

This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy.

The findings are:

A record review of the facility's fire drill records on 07/19/10 at approximately 9:45am indicated the following:

1. A night drill was not conducted for the 2nd quarter of 2010.
2. Details of the fire drills were not documented. For example the fire drill records did not indicate staff familiarity with fire safety procedures i.e. use of alarms, response to alarms, evacuation etc. Examples of the fire drills that were not fully documented included drills that were conducted on:
- May 30, 2010 at 9:15pm
- April 29, 2010 at 7:45pm
- April 19, 2010 at 8:00pm.
- February 02, 2010 at 11:20pm.

In an interview at approximately 10:45am, the Director of Environmental Services stated that an outside company was responsible for conducting and documenting the fire drills, and that he would inform the fire drill conductor to fully document them according to the regulations.

2000 NFPA 101 LSC; 19.7.1
NYCRR 415.26