Cortlandt Healthcare LLC

Deficiency Details, Certification Survey, February 1, 2012

PFI: 1041
Regional Office: MARO--New Rochelle Area Office

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F456 483.70(c)(2): ESSENTIAL EQUIPMENT IN SAFE OPERATING CONDITION

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

The facility must maintain all essential mechanical, electrical, and patient care equipment in safe operating condition.

Citation date: February 1, 2012

Based on observation and interview the facility did not ensure that essential equipment was working properly. Specifically the thermometer on the dish machine in the main kitchen was malfuntioning.

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

The findings are:

An initial tour of the main kitchen was conducted on 1/26/12 at 9:00AM. In the dish room where the dish machine is located an observation was made that the thermometer that records the rinse temperature was not funtioning properly. At the time of the observation, the dish machine was running but the thermometer was reading 40-50 degrees F. The thermometer was difficult to read due to the cloudyness of the cover. The standard rinse temperature is 180 degrees F.

In an interview with the food service manager at that time, he stated that he would make sure the thermometer gets fixed.

A second observation on 2/1/12 at 8:45AM (6 days later) revealed that the thermometer was still malfunctioning. The dish machine was running at the time of the observation and the thermometer was still reading 40-50 degrees F.

415.5(e)(1)(2)

F279 483.20(d), 483.20(k)(1): DEVELOP COMPREHENSIVE CARE PLANS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

A facility must use the results of the assessment to develop, review and revise the resident's comprehensive plan of care. The facility must develop a comprehensive care plan for each resident that includes measurable objectives and timetables to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The care plan must describe the services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under 483.25; and any services that would otherwise be required under 483.25 but are not provided due to the resident's exercise of rights under 483.10, including the right to refuse treatment under 483.10(b)(4).

Citation date: February 1, 2012

Based on record review and interviews a care plan with measurable objectives, timetables, and specific interventions to address an identified decline in continence was not developed for 1 out of 2 residents reviewed for a decline in continence status (Resident # 29).

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

The findings are:

Resident # 29 is a 91 year old male admitted with diagnoses which include but are not limited to Hypertension (HTN), Diabetes, Anemia, Atrial Fibrillation (A-fib), and Dementia. It was noted that the resident was able to make most of his needs known.

According to the resident's 8/28/11 comprehensive MDS (Minimum Data Set) assessment, the resident was frequently incontinent (7 or more episodes of urinary incontinence but at least one episode of continence voiding). MDS assessments also noted that the resident was on a toileting program with no improvement in continence.

The subsequent 11/9/11 MDS assessment indicated that the resident was then always incontinent of urine (no episodes of continent voiding) and not on any toileting program.

A review of the Certified Nursing Assitant (CNA) care flow sheets from July through September, 2011 revealed the resident was frequently incontinent with toileting and occasionally continent with toileting. CNA care flow sheets from November, 2011 through January, 2012 indicated that the resident was then always incontinent.

A review of the current CNA Plan of Care noted, inconsistent with the above, that the resident was continent of bladder.

The CNA assigned to the resident was intereviewed at 2:10PM on 2/1/12. The CNA stated that he did not normally work on this unit but had taken care of the resident in the past. He stated the resident was incontinent on this day but the resident did not ask for a urinal as he did in the past.

The evening shift CNA was interviewed at 3:20PM on 2/1/12. The CNA stated that she had taken care of the resident "for years." The CNA stated that, in the past, the resident would ask for the urinal and was continent. She stated that now, the resident never asks for the urinal and is always incontinent. The CNA stated the resident is not on any toileting program and that she has her own routine where she toilets the resident. She stated that at times the resident will void when placed on the toilet but he does not ask to be toileted as in the past.

The RN unit manager was asked, at 3:30PM on 2/1/12, about the resident's continence status. The RN was not aware that the resident was currently demonstrating a decline in continence. She stated that the resident was "mostly continent now."

There was no evidence in the resident's 9/20/11 Interdisciplinary Plan of Care for Urinary Incontinence related to Urinary Tract Infection, or elsewhere in the record, that a care plan had been developed to address the resident's decline in urinary continence. Urinary Tract Infection, often a result of incontinence and/or inadequate incontinence care, was identified as the cause of the resident's incontinence. There was no evidence of a plan to attempt to identify other factors in the environment of care that could potentially be associated with incontinence episodes, in order possibly return the resident to his previous level of continence. There was no evidence that toileting in the form of offering the urinal to the resident, whether or not he was able to request it himself any longer, or other interventions were considered or ruled out to attempt to maintain episodes of continence.

There was no evidence in the Physician's Progress Notes or Consultation Reports that a plan was identifed to address the resident's decline in urinary continence.

415.11(c)

F441 483.65: FACILITY ESTABLISHES INFECTION CONTROL PROGRAM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Citation date: February 1, 2012

Based on observations and staff interviews, the the facility did not ensure that acceptable procedures were used by staff to minimize the potential for development and spread of infection. Specifically, by not following proper hand washing procedures for Residents #75 and #92 during a dining observation and for hand washing, changing gloves and proper handling of a urinary catheter during cares for Resident #53.

This was evident for three residents during random observations and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. On 01/26/11 at 12:10 PM during a dining observation a Certified Nurse Aide (CNA) was observed repositioning a Resident #75 in a recliner chair in preparation for assisting her with lunch. The CNA was observed repositioning the resident's feet and legs, touching her pants and socks in the process. He then handled the mechanism at the bottom of the foot rest to lower the resident's legs and handled the mechanism that raised the head of the chair. The CNA then proceeded to feed the resident and shortly thereafter turned to Resident #92 to feed her, touching the trays and utensils of both residents.

During an interview with the CNA at 12:30 PM the CNA stated that he should have washed his hands between repositioning the resident and touching items on both of the residents' meal trays.

2. Resident #53 had a suprapubic catheter (a catheter inserted through the lower abdomen into the urinary bladder to drain urine into a collection bag). According to labaratory reports, the resident also had a history of multiple Urinary Tract Infections (UTI) between 3/21/11 - 9/28/11.

On 01/31/12 at 9:35 AM, a CNA was observed providing care for the resident while wearing gloves. After completing the resident's care, the CNA prepared to transfer the resident out of bed using a mechanical lift device at 10:05AM. The CNA then picked up and moved the resident's unlined and visibly soiled trash can. Without changing her gloves or sanitizing her hands, the CNA touched the resident's rolling bedside table, the mechanical lift device, the linens on the resident's bed and chair. The CNA and a Licensed Practical Nurse (LPN) then transferred the resident to the recliner chair using the lift. The CNA did not change her gloves. She then prepared mouth care supplies and cleansed the resident's mouth again without changing her gloves.

The CNA was interviewed at 10:15AM on 1/31/12. The CNA stated that she should have changed her gloves and washed her hands after she touched the trash can because her hands were then soiled. She stated that she contaminated the things she touched after that including the mechanical lift, linens, mouth care items, the resident's clothing and the resident's mouth.

3. Continuing the same observation as above, at 10:10AM on 1/31/12, the CNA and another staff member secured the resident's urine collection bag on a hook on the mechanical lift device about one foot above the level of the resident's reclining body. The bag and tubing remained above the level of the resident's bladder throughout the transfer to the recliner chair.

At 10:15 AM, during an interview with the CNA following the above observation, the CNA stated that she was not supposed to raise the urine collection bag above the level of the resident's body because it causes urine to back flow. She stated that the resident had a history of UTIs and that elevating the collection bag and the resulting back flow can lead to UTIs.
415.19

F164 483.10(e), 483.75(l)(4): PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

The resident has the right to personal privacy and confidentiality of his or her personal and clinical records. Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. Except as provided in paragraph (e)(3) of this section, the resident may approve or refuse the release of personal and clinical records to any individual outside the facility. The resident's right to refuse release of personal and clinical records does not apply when the resident is transferred to another health care institution; or record release is required by law. The facility must keep confidential all information contained in the resident's records, regardless of the form or storage methods, except when release is required by transfer to another healthcare institution; law; third party payment contract; or the resident.

Citation date: February 1, 2012

Based on observation and interview the facility did not ensure a resident's right to privacy during personal care and toileting. Specifically, a resident who was sharing a room with another resident did not have personal privacy during personal care and toileting, due to the inadequacy of the privacy curtain between the two beds.

This was evident for one resident (Resident # 223) and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During observation of Resident #223 on 1/27/12 at 1:20PM it was noted that the privacy curtain was not adequate to provide personal privacy for the resident when receiving personal care or using the commode. This was reported to a member of staff who came to the door during the interview at the above time.

This matter was again reported to the unit secretary on 1/27/12 at 3:15PM, who at this time reported the matter to the maintenance staff.

The curtain was provided on 1/30/12 at 12:00 Noon by the maintenance person, which was 4 days later from the initial report. The maintenance worker was asked why it took so long to correct this problem and he responded that he did not become aware of the issue until after it was identified by the surveyor. He stated that once he was informed, the facility did not have any extra curtains but some new curtains were received this morning.

The Administrator was interviewed at 11:00AM on 1/31/12 and at that time he stated that the maintenance employee had not reported the matter to anyone on 1/27/12, nor did he ask anyone about extra curtains. The Administrator further stated that there was a box containing curtains in a closet in the laundry and the maintenance worker apparently did not know where to look for the extra curtains in the laundry.

415.3(d)(1)


F318 483.25(e)(2): RANGE OF MOTION TREATMENT AND SERVICES

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

Based on the comprehensive assessment of a resident, the facility must ensure that a resident with a limited range of motion receives appropriate treatment and services to increase range of motion and/or to prevent further decrease in range of motion.

Citation date: February 1, 2012

Based on observation, interview and record review, adequate evaluation of lower extremity ROM (range of motion) was not performed, and sufficient assessment information was not available, for a resident with contractures of his hip, knee and ankle in order to determine whether the resident experienced improvement, deterioration or no change in his ROM.

This was evident for one of three residents reviewed for ROM and resulted in the potential for more than minimal harm that is not immediate jeopardy (Resident #53).

The findings are:

Resident #53 was admitted to the facility on 3/13/09 and had diagnoses including Dementia, Parkinson's disease, Stroke and Neurogenic Bladder.
Contractures of both of the resident's lower extremities, including his hip, knee and ankle, were observed while the resident was lying in bed as a CNA (Certified Nurse Aide) provided care to him at 4:30PM on 1/30/12.

A Contracture Screen completed by a Physical Therapist (PT) on 12/8/11 noted contractures of the resident's hip, knee and ankle. The PT identified a Plan of Action for the resident to have ROM included in his ADLs (activities of daily living).

According to the resident's 1/1/12 comprehensive MDS (Minimum Data Set) assessment, he was totally dependent on others to perform his ADLs.

The resident's ADL Interdisciplinary Plan Of Care, most recently reviewed on 1/11/12, included an intervention to perform ROM to the resident's lower extremities during ADLs in order that the resident not experience complications of immobility including contractures.

A CNA was observed providing morning care to the resident at 9:45AM on 1/31/12 including washing, performing skin care, dressing and transferring the resident out of bed to a recliner chair. No ROM was observed to be provided by the CNA.

The CNA was interviewed following the above observations at 10:15 AM on 1/31/12. The CNA stated that the resident was supposed to receive ROM with his morning care but that she was too busy to provide ROM that day. The CNA stated that she had moved the resident's legs in order to put on his pants but that she understood that those actions did not represent the required ROM activities. The CNA stated that she only does the resident's ROM on the days that she has time.

The resident's clinical record was reviewed in order to determine whether the resident experienced improvement, deterioration or no change in the degree of his lower extremity contractures and ROM. The 12/16/10 Contracture Screen did not include evaluation of contractures or ROM in the resident's hips, knees or ankles. There was no evidence in the 3/4/10, 4/21/11 and 1/30/12 Physical/Occupational/Speech Therapy Screens, or elsewhere in the resident's clinical record, of adequate assessment information to make a determination.

The Physical Therapist (PT) who completed the 12/08/11 Contracture Screen was interviewed at 11:30AM on 2/1/12. The PT reviewed the resident's clinical record, including additional records that were maintained in the rehabilitation therapy department. The PT stated that an annual assessment of the resident's lower extremity contractures had not been performed in the prior year and that no other sufficient evidence of prior assessments was available in order to evaluate whether or not the degree of the resident's lower extremity contractures had changed.

415.12(e)(2)

F315 483.25(d): RESIDENT NOT CATHETERIZED UNLESS UNAVOIDABLE

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

Based on the resident's comprehensive assessment, the facility must ensure that a resident who enters the facility without an indwelling catheter is not catheterized unless the resident's clinical condition demonstrates that catheterization was necessary; and a resident who is incontinent of bladder receives appropriate treatment and services to prevent urinary tract infections and to restore as much normal bladder function as possible.

Citation date: February 1, 2012

Based on interview, and record review, a resident with a decline in urinary continence did not receive the services necessary to restore or maintain the greatest degree of urinary continence possible. Specifically, (A) Resident #29 was not provided with interventions to minimize episodes of incontinence. Additionally, (B). the resident was not assessed to determine actual or potential causative factors associated with his decline in continence status in order to provide interventions to restore the resident to his previous level of continence or prevent further decline.

This was evident for one of two residents reviewed for urinary incontinence (Resident #29) and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident #29 was admitted to the facility on 1/18/08 and had diagnoses including hypertension.

According to the 7/26/11 MDS (Minimum Data Set) (an assessment tool) assessment and the 8/18/11 MDS assessment for a significant change in status following a four day hospitalization for anemia, the resident was cognitively impaired but usually/sometimes understood others and was able to make himself understood. The MDS assessments also indicated that the resident required the extensive assistance of one person for walking in his room and for toilet use and was frequently incontinent of urine. The 8/18/11 MDS further noted that a trial of a toileting program had been attempted without improvement in continence status.

The subsequent 11/9/11 MDS noted that the resident usually understood others, was able to be understood. The MDS again indicated that the resident required the extensive assistance of one person for walking in is room and for toilet use but that he was then always incontinent of urine. The MDS stated that no toileting program was in place.

The 9/20/11 Care Plan that addressed incontinence and the CNA (Certified Nurse Aide) Care Plan and flow sheets from 7/11 - 1/12 were reviewed and included no instructions for a toileting schedule or other interventions to minimize episodes of incontinence for the resident.

The day shift CNA assigned to care for the resident was interviewed at 2:00PM on 2/1/12. The CNA stated that the resident was not always incontinent prior to hospitalization and that he used to ask for the urinal. The CNA stated that, now, the resident is always incontinent and no longer asks for the urinal. The CNA stated that the resident is not on a toileting schedule and that he changes the resident when wet.

An evening shift CNA, who stated that she has known and cared for the resident for years, was interviewed at 3:10PM on 2/1/12. The CNA stated that the resident used to be continent and that he knew when he had the urge to urinate and asked for the urinal. The CNA stated that the resident no longer asks for the urinal and is almost always incontinent now.

The CNA further stated that a toileting schedule is not in place for the resident but that she tries to toilet the resident before and after dinner and at about 10:00PM when she is assigned to his care. The CNA stated that the resident urinates when she toilets him but is incontinent when she does not take him to the toilet.

The unit RN was interviewed at 3:15PM on 2/1/12 and stated that the resident is "now mostly continent."

There was no evidence in the clinical record (and the facility did not provide evidence) of attempts to identify patterns of incontinence episodes, contributory factors such as fluid intake, frequency of toileting, scheduled toileting or timely access to assistance for toileting in order to implement measures to restore urinary continence or prevent further decline based on the resident's individual needs.

B. An entry in the 10/16/11 Physician's Progress Notes indicated that the resident was "mostly continent." Subsequent Physician's Progress Notes dated 11/3/11 - 1/27/12 stated that the resident was incontinent.

There was no evidence in the Physician's Progress Notes, Assessments, Consultant Reports or elsewhere in the clinical record (and the facility was unable to provide evidence) of an evaluation by the resident's Physician, any other Physician or qualified health professional to determine a physical cause, illness or medical condition related to the resident's decline in urinary continence.

The unit RN, in the interview noted above, stated that there had been no evaluation of the resident to attempt to determine the cause of his decline in urinary continence status.

415.12(d)(2)

F282 483.20(k)(3)(ii): SERVICES BY QUALIFIED PERSONS IN ACCORDANCE WITH CARE PLAN

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

The services provided or arranged by the facility must be provided by qualified persons in accordance with each resident's written plan of care.

Citation date: February 1, 2012

Based on observation, interview and record review, ROM (range of motion) care was not provided for a resident with contractures of his lower extremities to prevent further complications of immobility according to his Interdisciplinary Plan of Care. This was evident for one of three residents (Resident #53) reviewed for ROM and resulted in the no actual harm with potential for more than minimal harm that is not immediate jeopardy.
The findings are:

Resident #53 was admitted to the facility on 3/13/09 and had diagnoses including Dementia, Parkinson's disease, Stroke and Neurogenic Bladder.

Contractures of both of the resident's lower extremities, including his hip, knee and ankle, were observed while the resident was lying in bed as a CNA (Certified Nurse Aide) provided care to him at 4:30PM on 1/30/12.

The Physical Therapist (PT) completed a Contracture Screen on 12/8/11 and noted contractures of the resident's hip, knee and ankle. The PT identified a Plan of Action for the resident to have ROM included in his ADLs (activities of daily living).

According to the resident's 1/01/12 comprehensive MDS (Minimum Data Set) assessment, he was totally dependent on others to perform his ADLs.

The resident's ADL Interdisciplinary Plan Of Care, most recently reviewed on 1/11/12, included an intervention to perform ROM to the resident's lower extremities during ADLs in order that the resident not experience complications of immobility including contractures.

A CNA was observed providing morning care to the resident at 9:45AM on 1/31/12 including washing, performing skin care, dressing and transferring the resident out of bed to a recliner chair. No ROM was observed to be provided by the CNA.

The CNA was interviewed following the above observations at 10:15 AM on 1/31/12. The CNA stated that the resident was supposed to receive ROM with his morning care but that she was too busy to provide ROM that day. The CNA stated that she had moved the resident's legs in order to put on his pants but that she understood that those actions did not represent the required ROM activities. The CNA stated that she only does the resident's ROM on the days that she has time.

415.11(c)(3)(ii)

K72 NFPA 101: FURNISHING AND DECORATIONS

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

Means of egress are continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects obstruct exits, access to, egress from, or visibility of exits. 7.1.10

Citation date: February 1, 2012

Based on observation and interview it was determined that the facility did not ensure that the means of egress were continuously maintained free of all obstructions or impediments to full use in the event of fire or other emergency. This was evidenced by the storage of unattended resident and nursing equipment in exit access corridors on two of three nursing units, on two of three floors (floors 1 and 2).

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

Findings are:

On 1/26/12 during life safety rounds conducted between 11:00 AM and 1:00 PM, unattended resident and nursing equipment was observed to be stored directly against the handrails and between smoke barrier doors in exit access corridors. Some of the equipment was noted to be plugged into corridor outlets. This situation could create an impediment to the full and instant use of the corridors as well as prevent smoke barrier doors from closing in the event of an emergency.
Examples include (not inclusive):

1st floor:
- At 11:20 AM, one Hoyer lift was stored in the middle of the corridor, between an open set of smoke barrier doors. A second Hoyer lift, one large clean linen cart and a partially full two-compartment soiled linen cart were stored in the corridor between resident rooms # 107 and # 118. The Hoyer lift blocking the smoke barrier doors was removed from the corridor immediately when the Maintenance Director brought it to the attention of a nurse.

2nd floor:
- At 11:30 AM, one Hoyer lift was stored at the end of the corridor and one scale was plugged into a corridor outlet between resident room # 214 and the soiled utility room. In an interview at the time regarding the use and storage of this Hoyer lift, a nurse on the unit stated that "we are pretty much done using it, and that it charges in the corridor when not in use".

- At 12:15 PM, while lunch was in progress, a full double compartment soiled linen cart was observed to be stored in the corridor outside resident rooms # 202 and # 204. Upon questioning at that time regarding the storage of full soiled linen carts, a housekeeper stated that, at the request of the Certified Nurse Aides, the full carts are placed in the shower rooms, and then emptied into the soiled utility room. She immediately placed the cart in the shower room.

- At 12:30 PM, one scale was observed to be plugged into a corridor outlet directly outside of resident room # 214.

Although staff members interviewed on 1/26/12 indicated that the corridors would be cleared in the event of a fire or smoke emergency, review of fire drill records the same day at approximately 1:15 PM revealed that corridor storage had been identified as a concern during a fire drill conducted on 5/16/11. In particular, the fire drill comments noted that "... a Hoyer lift and a couple of wheelchairs on the 3rd floor".

In an interview at approximately 12:30 PM the same day, the Maintenance Director stated that equipment storage options would be discussed with the nursing staff as well as during future fire drills and in-services.

2000 NFPA 101: 7.1.10
NYCRR 711.2(a)(1)

K76 NFPA 101: MEDICAL GAS SYSTEM

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

Medical gas storage and administration areas are protected in accordance with NFPA 99, Standards for Health Care Facilities. (a) Oxygen storage locations of greater than 3,000 cu.ft. are enclosed by a one-hour separation. (b) Locations for supply systems of greater than 3,000 cu.ft. are vented to the outside. NFPA 99 4.3.1.1.2, 19.3.2.4

Citation date: February 1, 2012


2000 NFPA 101 Chapter 19.3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, \i Standard for Health Care Facilities .
1999 NFPA 99 Chapter 16-3.8.1 states that equipment shall conform to requirements for patient equipment in Chapter 8.

1999 NFPA 99 Chapter 8-3.1.11.2 states, Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.

This Standard is not met as evidenced by:

Based on observation and interview, the facility did not ensure that medical gas is stored in accordance with NFPA 99 in that oxygen tanks were stored within 20 feet of combustible materials on two of three nursing units on 2 of 3 floors (2nd and 3rd ). The nursing units are not sprinklered.

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

Findings are:

On 1/26/12 between 9:00 AM and 2:00 PM during life safety rounds, it was noted that, except for two loading docks, the facility lacks automatic sprinkler protection. A tour of the 3 nursing units (floors 1 - 3) revealed that small 'e' oxygen cylinders are stored together with nursing and resident supplies in rooms labeled 'Supplies'. These cylinders were noted to be within 5 feet of combustible materials, paper and plastic resident care and nursing supplies. Specifically, 14 'e' cylinders were stored in the 3rd floor Supplies room and 5 cylinders were stored in the 2nd floor Supplies room. Both of these rooms were noted to be cluttered with supplies and storage carts.

In an interview the same day at 9:15 AM, the Maintenance Director concurred with the observations.

2000 NFPA 101: 19.3.2.4
1999 NFPA 99: 8-3.1.11.2
711.2(a)(1)

K67 NFPA 101: VENTILATING EQUIPMENT

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: March 16, 2012

Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Citation date: February 1, 2012

Based on observation and interview it was determined that all fire dampers were not maintained in proper operational condition necessary to ensure that they would close in the event of a fire. This was noted for one of six dampers located on one of three nursing units (3rd floor). This situation could result in the horizontal spread of fire in the event of an emergency.

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

The finding is:

On 1/26/12 between 12:30 PM and 1:30 PM, the smoke barrier walls above the suspended ceilings were examined. It was noted that, above each set of smoke barrier doors, there are fire dampers equipped with fusible links. These dampers are designed to close in the event of a fire emergency. However, it was observed that a bundle of cables passed completely through the damper above the barrier doors near resident rooms #301 and 306 on the 3rd floor. This condition would prevent the damper from closing in the event of a fire.

In an interview at that time, the Director of Maintenance stated that he would have the cables re-routed.

2000 NFPA 101: 8.3.5
1996 NFPA 90A: 3-4.5.1
NYCRR 711.2(a)(1)

K18 NFPA 101: CORRIDOR DOORS

Scope: Pattern

Severity: Potential for no more than Minimal Harm

Corrected Date: March 16, 2012

Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas are substantial doors, such as those constructed of 1 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Doors in sprinklered buildings are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Doors are provided with a means suitable for keeping the door closed. Dutch doors meeting 19.3.6.3.6 are permitted. 19.3.6.3 Roller latches are prohibited by CMS regulations in all health care facilities.

Citation date: February 1, 2012

Based on observation and interview, it was determined that the facility did not ensure that there are no impediments to the closing of corridor doors and that doors are maintained to latch positively and/or close tightly to resist the passage of smoke. Reference is made to doors that were propped open using unapproved hold open devices (i.e. chocks) and to corridor doors that did not latch positively when closed.

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

The findings are:

On 1/26/12 during life safety rounds conducted between 9:00 AM and 2:00 PM, the following was noted:

1. Doors were held open by unapproved hold-open devices, i.e. wood and plastic 'chocks' or wedges. Examples include: Rehabiliation Suite door, laundry suite door.

2. Corridor doors to resident rooms did not latch positively when tested. Examples include resident rooms # 307 and # 109.

In an interview at the time, the Maintenance Director stated that he would replace the unapproved hold open devices. He further stated that adjustments would be made to the strike plates on the resident doors to ensure that they latch and close properly.

2000 NFPA 101: 19.3.6.3
711.2(a)(1)