Lutheran Retirement Home

Based on observation, record review and staff interview, the facility did not ensure the staff accurately and completely documented the nutritional supplements consumed with and between meals. Two (Residents #76, 103) of three residents identified as at risk for nutritional issues including weight loss and dehydration had issues including incomplete and inaccurate documentation of the between meals and with meal nutritional supplements. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #76 has diagnoses including anemia, heart failure, hypertension, seizures, macular degeneration and dementia. Review of the Minimum Data Set (MDS) dated 7/28/11 revealed the resident is usually understood and usually understands, and has a cognitive score of 8/15 which indicates the resident is moderately impaired in daily decision making.

Observation on 10/18/11 at approximately 12:50 PM revealed the resident ate approximately 25% of his potatoes when fed by staff. Review of the Meal Intake Sheets dated 10/18/11 revealed the certified nurse aides (CNAs) documented the resident consumed 75% of all of the foods and did not document separately the consumption of the nutritional supplements.

Interview with the Registered Dietitian (RD) on 10/19/11 at approximately 10:00 AM revealed Resident #76 has lost weight and is to receive the following nutritional supplements at meals: "Super" (fortified) cereal at breakfast and "super" potatoes at lunch. During this time, Meal Intake Sheets dated 3/28/11 through 10/18/11, that the CNAs use to document the nutritional supplements given with the meals, were reviewed with the RD. On the sheets, the CNAs were inaccurately and incompletely documenting the actual nutritional supplement consumed by the resident. The Meal Intake Sheets were either blank or the documentation was incorrect because the documentation of the nutritional supplement was not separated out from the regular meal. Additionally, the RD stated she reviewed the Meal Intake Sheets documenting the nutritional supplements consumed weekly and saw that the CNAs were not documenting on the Meal Intake Sheets or incorrectly documented the nutritional supplements. The RD stated she did not report to the Administrator or the Director of Nursing (DON) that the CNAs continued to inaccurately and/or incompletely document the residents' nutritional supplements consumed.

Interview with the DON and the Administrator on 10/19/11 at approximately 11:00 AM revealed the Administrator and the DON stated neither the RD nor the Interdisciplinary Team (IDT) reported that the CNAs were not completely and/or correctly documenting the nutritional supplements consumed separately from the meal consumption.

Review of facility policy entitled Food Intake Records with a revision date of 9/09 revealed for those residents identified as high nutritional risks, the nursing staff following each meal will fill in the amount of food, protein and fluids and special consumed foods (i.e. custards, puddings, milkshakes and boost). The meal is the total of the food on the tray. The sheets will be reviewed at least weekly and will be discussed with the Unit Manager at the meeting.

Review of the policy entitled Nourishment with a review date of 12/09 revealed the staff will document the amount consumed by residents and at the end of each shift the nurse will review the nourishment sheets for documentation of consumption and refusals. Any dietary concerns can be discussed at the daily IDT meeting. The RD/Diet Tech will review the nourishment sheets weekly consumption.

Interview on 10/19/11 at 10:00 AM with RN UM #1 revealed she thought the CNAs were documenting the nutritional supplements correctly but realized now the CNAs have been documenting incorrectly.

Interview on 10/19/11 at 10:30 AM revealed RN UM #2 stated "I did not know the CNAs were not documenting the nutritional supplements correctly. I thought as long as the CNAs documented the total amount of fluids consumed that is all that was needed.

Interview on 10/19/11 at 1:00 PM revealed CNA #1 stated she doesn't remember being inserviced on how to document on the Meal Intake Sheets. CNA #1 stated if a supplement is given with a meal, she documents it under fluid intake but didn't know she was to document the fluids separately from the supplements.

Interview with CNA #3 on 10/19/11 at 1:45 PM revealed she documents all fluids consumed by a resident under "fluids in cc amounts" including supplements like Ensure and all solids under percentages of solids.

2. Resident #103 has diagnoses including advanced dementia - Alzheimer's type, hypertension, osteoporosis, and depression. Review of the Minimum Data Set (MDS) dated 10/13/11 revealed the resident is rarely/never understood, usually understands and is severely impaired in daily decision making. The resident requires one person extensive assist for eating.

Observation of the resident on 10/18/11 at approximately 12:30 PM revealed a certified nurse aide (CNA) was feeding the resident and using a cup with no lid to give the resident fluids. The resident was observed to consume approximately 25% of her super potatoes. Review of the Meal Intake Sheet documentation revealed the resident consumed 75% of all of the foods and did not identify the actual consumption of the nutritional supplements. Further observation on 10/24/11 at approximately 3:15 PM revealed the resident consumed all of the milk shake for the CNA.

Interview with the RD on 10/19/11 at approximately 10:00 AM revealed the resident is to receive 4 ounces (oz) of a milkshake at 3:00 PM daily and super cereal at breakfast, super potatoes at lunch and super soup at supper. Review of the Meal Intake Sheets dated 4/4/11 through 10/18/11 with the RD during this time confirmed the CNAs incorrectly and/or incompletely documented the resident's consumption of the nutritional supplements with meals.

415.22(a)(1)(2)

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 11/18/10.

Based on observation, record review and staff interview, the facility did not ensure each resident's drug regimen was free from unnecessary drugs. Five (Residents #123, 128, 195, 203, 214) of ten residents reviewed for unnecessary medications had issues involving use of medication for an excessive duration without adequate monitoring, indication for use, or gradual dose reduction. In addition, there were two different medication orders for itching that did not include which of the two ordered medications should be given first and incomplete physician orders for temperature parameters for the administration of Tylenol. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to:

1. Resident #123 has diagnoses including Alzheimer's disease and anxiety disorder. Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident is rarely/never understood, sometimes understands, and is severely impaired in daily decision making. Further review of the MDS revealed the resident did not exhibit any physical or verbal behavioral symptoms towards others and received antipsychotic and anti-anxiety medications during the last 7 day look back period.

Intermittent observation of the resident during the survey dated 10/18/11 through 10/25/11 between approximately 8:00 AM through 5:00 PM revealed the resident did not exhibit any verbal or physical behaviors. The resident was observed walking around the unit in her merrywalker.

Review of Physicians Orders dated 5/9/11 through 9/23/11 revealed the following orders:

- Lorazepam (used to treat anxiety) 0.5 milligrams (mg) tablet take 1/2 tablet (0.25 mg) PO (by mouth) QD (every day) at 6:00 PM - agitation
- Seroquel (antipsychotic medication) 25 mg tablet 1 po QHS (every bedtime) at 7:00 PM - agitation

Review of the Medication Administration Records (MARs) dated 6/11 through 10/20/11 revealed the nurses documented that the resident received both medications as ordered except approximately 5 times when the resident refused the Lorazepam and Seroquel.

Review of Physician Notes dated 10/10/10 through 10/10/11 revealed no documentation of indications for the continued use of Seroquel and Lorazepam.

Review of the Medication Record Review completed by the Pharmacist Consultant dated 10/14/10 through 10/10/11 revealed no irregularities were noted regarding the continued use of Seroquel or Lorazepam. In addition, there were no yearly reviews for consideration of gradual dose reductions as per Federal regulations. The last recommendation for a GDR of the Seroquel was dated 1/10/08 and the last recommended GDR for the Lorazepam was dated 4/17/10.

Interview with the Registered Nurse (RN) Unit Manager (UM) for Unit B2 on 10/21/11 at approximately 2:30 PM revealed review of the Physician Notes and Progress Note Reports dated 6/9/11 to 10/25/11 revealed there are no recommendations from the Pharmacist Consultant for gradual dose reductions of the Seroquel since 1/10/08 and 4/17/10 for the Lorazepam. The RN UM stated there are no psychiatric or psychological consults for this resident since 6/6/07 when the Psychiatrist recommended continuation of the Seroquel 25 mg po qhs. The Psychiatrist recommended on 7/21/10 to continue a low dose of Xanax or Lorazepam 0.25 mg for anxiety. The RN UM further stated the resident has declined cognitively and has not exhibited any behaviors in the past year or more. The RN UM stated on the last psychiatric consult visit dated 7/21/10 the Psychiatrist recommended a merrywalker for the resident's restlessness.

Interview with the Pharmacist Consultant on 10/24/11 at 3:20 PM revealed the Pharmacist Consultant stated he did not recommend a GDR for the Seroquel or the Lorazepam and "just missed it". Discussed with the Pharmacist Consultant neither the Physician nor the Nurse Practitioner documented any indications for the continued use of Seroquel and Lorazepam for this resident. The Pharmacist Consultant stated he "was negligent".

During an interview with the Nurse Practitioner (NP) on 10/24/11 at 3:30 PM, the NP stated there is no documentation for the continued use of Lorazepam or the Seroquel and she wrote a discontinuation order for the Lorazepam on 10/21/11. The NP further stated she spoke to the Pharmacist Consultant and the Pharmacist Consultant stated to only discontinue one medication at a time to evaluate the effect on the resident. The Physician was unavailable for interview.

Review of the Plan of Care dated 9/13/11 revealed that the resident receives antipsychotic (Seroquel) and anxiolytic (Ativan) medications daily. The interventions listed include that the Interdisciplinary Team (IDT) is to review psychotropic medications monthly.

Review of the IDT notes dated 9/13/11 revealed no review of the resident's antipsychotic and anxiolytic medication use.

Review of the IDT meeting notes dated 6/21/11 revealed the Social Worker documented the "IDT reviewed psych meds" without any further documentation.

2. Resident #195 has diagnoses of rheumatoid arthritis and severe peripheral vascular disease. Review of the Minimum Data Set (MDS) dated 8/16/11 identified the resident as being cognitively intact.

A review of Physician Orders revealed a telephone order 1/25/10 dated for Atarax 25 milligrams (mg) orally every 6 hours for itching. A 7/17/10 telephone order revealed an order for Benadryl 50 mg orally every 6 hours for itching.

Review of the Physician Standing Orders dated 10/4/11 revealed orders for Diphenhydramine 50 mg orally every 6 hours as needed for itching and Hydroxyzine (Atarax) 25 mg orally every 6 hours as needed for itching. There were no parameters for which medication to give first.

Interview on 10/24/11 at 10:45 AM with the Licensed Practical Nurse (LPN) Medication Nurse revealed the resident has not complained of itching so she has not given either Benadryl or Atarax. If he complained of itching she would try one first. If it didn't work she would give the other.

An interview with the Registered Nurse (RN) Nurse Manager on 10/24/11 at approximately 2:00 PM revealed she would notify the physician and do a thorough review of the resident's medication orders.

Review of a verbal order dated 10/24/11 revealed an order to discontinue Atarax.

Additionally the 10/4/11 Physician Standing Orders revealed the following orders for Acetaminophen for pain or elevated temp: 650 mg suppository q4h (every four hours) prn (as needed); 325 mg two tabs q4h prn. There were no parameters indicated for the elevated temperature.

3. Resident #128 has diagnoses which include cerebral vascular accident (CVA - stroke), degenerative joint disease, and depression. Review of the Minimum Data Set (MDS) dated 9/27/11 revealed the resident had a BIMS (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score of 14 indicating the resident is independent in decision making.

Review of a Physician Order dated 10/18/11 with a start date of 5/12/11 revealed an order for Tylenol 325 mg (tablet) give 2 tablets (650 mg) po (by mouth) q 6 hrs prn (as needed) for pain or elevated temperature not to exceed 3 grams (gms) (3000 mg) in 24 hours. The physician's order lacked temperature parameters for administration of the Tylenol.

During an interview with the Unit A2 Registered Nurse (RN) Unit Manager (UM) on 10/21/11 at 2:00 PM, the RN stated according to their policy, the elevated temp is 101 or above. Interview with the Unit A1 Licensed Practical Nurse (LPN) Medication Nurse on 10/25/11 at 2:25 PM, revealed he would give Tylenol if the resident had a temperature of 100 or greater. Interview with the Unit A1 RN Medication Nurse on 10/25/11 at 2:43 PM revealed she would give it over 100.4 degrees. Interview with the Unit B1 RN Medication Nurse on 10/25/11 at 2:30 PM, the RN stated she would give the Tylenol for 100.5 degrees. Interview with the Unit B1 LPN Medication Nurse on 10/25/11 at 2:35 PM, the LPN stated she would give the Tylenol for a temperature of 101.5 degrees.

Interview with the Director of Nursing (DON) on 10/24/11 at 3:18 PM stated they have nine attending physicians and they all have their own standing orders with different parameters for Tylenol administration and temperature. It makes it very confusing for the staff.

415.12(l)(1)

Based on observation, record review and staff interview, the pharmacist did not report any irregularities to the Attending Physician and the Director of Nursing to be acted upon. Five (Residents #123, 128, 195, 203, 214) of ten residents reviewed for unnecessary medications had issues involving the lack of temperature parameters for administration of Tylenol (#128, 195, 203, 214). In addition, Resident #195 had issues involving lack of parameters for the administration of two antipruritic medications. There were no parameters for which medication to give first. Resident #123 had issues involving a lack of recommendation for a gradual dose reduction (GDR) of Lorazepam and Seroquel as required. This was a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy.
ne The findings include but are not limited to:

1. Resident #195 has diagnoses including severe peripheral vascular disease, rheumatoid arthritis and status post bilateral above knee amputations. Review of the Minimum Data Set dated 8/16/11 identified the resident as being cognitively intact.

a). Review of a Telephone Order dated 9/16/11 revealed a Physician's Order to discontinue Plavix (prevents platelet aggregation) and restart in two weeks if no further nosebleeds. The 9/30/11 Resident Calendar documented "Restart Plavix if no more nosebleeds; see order for 9/16/11". Review of the 10/4/11 Physician's Orders revealed no order for Plavix.

The Progress Note Report printed and submitted to the surveyor on 10/24/11 revealed no Interdisciplinary Notes to reveal the resident as having nosebleeds since 9/16/11.

An interview with the Registered Nurse (RN) Nurse Manager on 10/24/11 at approximately 2:00 PM revealed the follow up had been entered on the calendar and she found no documented evidence the resident had experienced nosebleeds since the Plavix had been discontinued on 9/16/11.

Review of the Medication Regimen Review dated 10/10/11 revealed no apparent irregularities and no recommendations.

An interview with the Pharmacy Consultant at 12:40 PM on 10/25/11 revealed he did not notice the Plavix had not been resumed.

b). A review of Physician Orders revealed a telephone order dated 1/25/10 for Atarax 25 milligrams (mg) orally every 6 hours for itching. A 7/17/10 telephone order revealed an order for Benadryl 50 mg orally every 6 hours for itching.

Review of the Physician Standing Orders dated 10/4/11 revealed orders for Diphenhydramine 50 mg orally every 6 hours as needed (prn) for itching and Hydroxyzine (Atarax) 25 mg orally every 6 hours as needed for itching. There were no parameters for which medication to give first.

Interview on 10/24/11 at 10:45 AM with the Licensed Practical Nurse (LPN) Medication Nurse revealed the resident has not complained of itching so she has not given either Benadryl or Atarax. If the resident complained of itching she would try one medication first. If it didn't work she would give the other.

Review of the Medication Regimen Review from 2/2/10 through 10/10/11 revealed no recommendations regarding a lack of parameters for administration of Atarax and Benadryl.

During an interview with the Pharmacy Consultant at 12:40 PM on 10/25/11 he stated that he assumes that if one medication for itching didn't work the nurse would administer the other.

c). Additionally the 10/4/11 Physician Standing Orders revealed the following orders for Acetaminophen for pain or elevated temp:

- 650 mg suppository q4h (every four hours) prn (as needed);
- 325 mg two tabs q4h prn.

There were no parameters indicated for the elevated temperature.

Review of the Medication Regimen Review from 2/2/10 through 10/10/11 revealed no recommendations regarding a lack of parameters for administration of Acetaminophen for elevated temperature.

2. Resident #123 has diagnoses including Alzheimer's disease, anxiety disorder, heart failure, OP (osteoporosis), arthritis, hypertension, and Stage 3 CKD (chronic kidney disease). Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident is rarely/never understood, sometimes understands, and is severely impaired in daily decision making. Further review of the MDS revealed the resident's vision is moderately impaired and does not wear corrective lenses. In addition, the Behavior Section of the MDS revealed the resident did not exhibit any physical or verbal behavioral symptoms towards others. Further review of the MDS revealed the resident received antipsychotic and anti-anxiety medications during the last 7 day look back period.

Intermittent observation of the resident during the survey dated 10/18/11 through 10/25/11 between approximately 8:00 AM through 5:00 PM revealed the resident did not exhibit any behaviors. The resident was observed walking around the unit in her merrywalker.

Review of Physician's Orders dated 5/9/11 through 9/23/11 revealed the following orders:

- Lorazepam 0.5 mg tablet take 1/2 tablet (0.25 mg) PO (by mouth) QD (every day) at 6:00 PM - agitation
- Seroquel 25 mg tablet 1 po QHS (every bedtime) at 7:00 PM - agitation

Review of the Medication Administration Records (MARs) dated 6/11 through 10/20/11 revealed the nurses documented that the resident received both medications as ordered except approximately 5 times when the resident refused the Lorazepam and Seroquel.

Review of Physician Notes dated 10/10/10 through 10/10/11 revealed no documentation of indications for the continued use of Seroquel and Lorazepam.

Review of the Medication Record Review completed by the Pharmacist Consultant dated 10/14/10 through 10/10/11 revealed no irregularities were noted regarding the continued use of Seroquel or the Lorazepam and there was no yearly review for consideration for gradual dose reductions as per Federal regulations. The last recommendation for a GDR of the Seroquel was dated 1/10/08 and the last recommended GDR for the Lorazepam was dated 4/17/10.

Interview with the Registered Nurse (RN) Unit Manager (UM) for Unit B2 on 10/21/11 at approximately 2:30 PM revealed review of the Physician Notes and Interdisciplinary Notes revealed there are no recommendations from the Pharmacist Consultant for gradual dose reductions of the Seroquel since 1/10/08 and 4/17/10 for the Lorazepam. The RN UM stated there are no psychiatric or psychological consults for this resident since 6/6/07 when the Psychiatrist recommended continuation of the Seroquel 25 mg po qhs. The Psychiatrist recommended on 7/21/10 to continue a low dose of Xanax or Lorazepam 0.25 mg for anxiety. The RN UM further stated the resident has declined cognitively and has not exhibited any behaviors in the past year or more. The RN UM stated on the last psychiatric consult visit dated 7/21/10 the Psychiatrist recommended a merrywalker for the resident's restlessness.

Further interview with the RN UM revealed the resident has not seen the optometrist for an eye consult since her admission 6/07 and "when the resident wanders throughout the unit she doesn't bump into anything so I guess she sees ok". The RN UM stated the resident's Plan of Care was reviewed at the Interdisciplinary Team (IDT) meeting held on 9/13/11 and stated they did not review the resident's Seroquel or Ativan. The RN UM further stated there were no care plan revisions for this resident since 8/8/10 when the resident was assessed and issued a merrywalker for her restlessness. The RN UM stated the resident does not exhibit any behaviors anymore and has had a decline in her cognitive status and that she needs to review the resident's Plan of Care to revise it for appropriate interventions.

Interview with the Pharmacist Consultant on 10/24/11 at 3:20 PM revealed the Pharmacist Consultant stated he did not recommend a GDR for the Seroquel or the Lorazepam and "just missed it". Discussed with the Pharmacist Consultant neither the Physician nor the Nurse Practitioner documented any indications for the continued use of Seroquel and Lorazepam for this resident. The Pharmacist Consultant stated he "was negligent".

Interview with the Nurse Practitioner (NP) on 10/24/11 at 3:30 PM revealed the NP stated there is no documentation for the continued use of Lorazepam or the Seroquel and she wrote a discontinuation order for the Lorazepam on 10/21/11. The NP further stated she spoke to the Pharmacist Consultant and the Pharmacist Consultant stated to only discontinue one medication at a time to evaluate the effect on the resident. The Physician was unavailable to interview.

Review of the Resident Care Card used by the certified nurse aides (CNAs) and dated 9/14/11 revealed the resident transfers from sitting to standing independently when in the merrywalker and the resident wanders around the unit.

Review of the Plan of Care dated 9/13/11 revealed that the resident receives antipsychotic (Seroquel) and anxiolytic (Ativan) medications daily. The interventions listed include that the Interdisciplinary Team (IDT) is to review psychotropic medications monthly.

Review of the IDT notes dated 9/13/11 revealed no review of the resident's antipsychotic and anxiolytic medication use.

Review of the IDT meeting notes dated 6/21/11 reveal the Social Worker documented the "IDT reviewed psych meds" without any further documentation.

Review of the policy entitled Care Planning with a revision date of 10/11 revealed the Nurse Manager will prepare for the Care Plan meeting. The Nurse Manager reviews and updates the MDS, assesses and observes the resident and discusses problems and needs with the staff. Each discipline is responsible for making appropriate care approaches and short and long term measurable goals.

Review of the facility policy entitled Medication Regimen Review with a revision date of 12/10 revealed the Pharmacist is responsible to evaluate medication orders to determine that the resident's orders represent optimal therapy for the individual and include indications for use, medications demonstrate a favorable benefit-to-risk ratio, prescribed dose is appropriate, duration of therapy is indicated and is appropriate. Psychoactive Drug Monitoring - the prescriber and the care planning team will reassess regularly the need for psychoactive use. If continued use is recommended this is indicated in the medical record.

3. Resident #128 has diagnoses which include cerebral vascular accident (CVA -stroke), degenerative joint disease, and depression. Review of the Minimum Data Set (MDS) dated 9/27/11 revealed the resident had a BIMS (Brief Interview for Mental Status - a brief screen that aids in detecting cognitive impairment) score of 14 indicating the resident is independent in decision making.

Review of a Physician Order dated 10/18/11 with a start date of 5/12/11 revealed an order for Tylenol 325 mg (tablet) give 2 tablets (650 mg) po q 6 hrs prn pain or elevated temperature not to exceed 3 gms (3000 mg) in 24 hours. The Physician's Order lacked parameters when to give Tylenol for what temperature.

Interview with the Registered Nurse (RN) Unit Manager (UM) on 10/21/11 at 2:00 PM stated according to there policy the elevated temp is 101 or above. Interview with the Unit A1 Licensed Practical Nurse (LPN) Medication Nurse on 10/25/11 at 2:25 PM stated he would give Tylenol if the resident had a temperature of 100 or greater. Interview with the Unit A1 RN Medication Nurse on 10/25/11 at 2:43 PM stated she would give it over 100.4 degrees. Interview with the Unit B1 RN Medication Nurse on 10/25/11 at 2:30 PM stated she would give the Tylenol for 100.5 degrees. Interview with the Unit B1 LPN Medication Nurse on 10/25/11 at 2:35 PM stated she would give the Tylenol for a temperature of 101.5 degrees.

Interview with the Director of Nursing (DON) on 10/24/11 at 3:18 PM stated they have nine attending physicians and they all have there own standing orders with different parameters for Tylenol administration and temperature. It makes it very confusing for the staff. The Medical Director reviewed all there parameters collectively and wrote a policy for standing orders for Tylenol administration for temperature of 101 or above. The policy has not been yet been implemented.

Review of the Medication Regimen Review dated 6/10/11 through 10/10/11 revealed the Consultant Pharmacist had no apparent irregularities in the resident medication regimen.

Interview with the Pharmacist on 10/25/11 at 12:40 PM revealed he thought the facility had a policy regarding temperature parameters for the administration of Tylenol so he did not make the recommendations for parameters.

415.18(c)(2)

Based on observation, record review and staff interview, the facility did not ensure the resident received proper treatment and assistive devices to maintain adequate vision. One (Resident #123) of three residents reviewed for vision without corrective lenses had issues that involved the lack of an eye appointment and/or arrangement for transportation services if needed. 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 #123 has diagnoses including Alzheimer's disease and anxiety disorder. Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident is rarely/never understood, sometimes understands, and is severely impaired in daily decision making. Further review of the MDS revealed the resident's vision is moderately impaired and she does not wear corrective lenses.

Intermittent observation of the resident during the survey dated 10/18/11 through 10/25/11 between approximately 8:00 AM through 5:00 PM revealed the resident was observed walking around the unit in her merrywalker. The resident was not observed reading any type of printed matter.

Review of the Plan of Care dated 9/13/11 revealed that the resident was identified with visual function problems, has no corrective lenses and ambulates independently in her merrywalker. The goals are that the resident's safety will not be compromised due to her visual deficit. The interventions include to make sure the resident has adequate lighting and assess for visual changes. There is no documented plan to assist the resident in gaining access to vision services by making an appointment or arranging for transportation. Review of the Resident Care Card used by the CNAs and dated 9/14/11 revealed no directions to address the resident's moderately impaired vision.

During an interview with the Registered Nurse (RN) Unit Manager (UM) for Unit B2 on 10/21/11 at approximately 2:30 PM, the RN UM stated the resident has not seen the optometrist for an eye consult since her admission 6/07 and stated "when the resident wanders throughout the unit, she doesn't bump into anything so I guess she sees ok". The RN UM stated the resident's Plan of Care was reviewed at the IDT (Interdisciplinary Team) meeting held on 9/13/11 and stated they did not review the resident's visual function. Review of the IDT notes dated 6/9/11 through 9/13/11 revealed no review of the resident's vision.

415.12(b)(1)

Based on observation, record review and staff interview, the facility did not revise the resident's care plan to reflect a change in the resident's behaviors. One (Resident #123) of 20 residents reviewed for care plan revisions had an issue that involved a lack of care plan revision to reflect the resident's decline in disruptive behaviors. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #123 has diagnoses including Alzheimer's disease and anxiety disorder. Review of the Minimum Data Set (MDS) dated 9/2/11 revealed the resident is rarely/never understood, sometimes understands, and is severely impaired in daily decision making. Further review of the MDS revealed the resident did not exhibit any physical or verbal behavioral symptoms towards others and received antipsychotic and anti-anxiety medications during the last 7 day look back period.

Review of the Plan of Care dated 9/13/11 revealed that the resident receives antipsychotic (Seroquel) and anxiolytic (Ativan - used to treat anxiety) medications daily. The interventions listed include that the Interdisciplinary Team (IDT) is to review psychotropic medications monthly.

Intermittent observation of the resident during the survey dated 10/18/11 through 10/25/11 between approximately 8:00 AM through 5:00 PM revealed the resident did not exhibit any behaviors. The resident was observed walking around the unit in her merrywalker.

Review of the IDT (Interdisciplinary Team) meeting notes dated 6/21/11 revealed the Social Worker documented the "IDT reviewed psych meds" without any further documentation.

Review of the IDT notes dated 9/13/11 revealed no review of the resident's antipsychotic and anxiolytic medication use.

When interviewed on 10/21/11 at approximately 2:30 PM, the Registered Nurse (RN) Unit Manager (UM) for Unit B2 stated the resident has declined cognitively and has not exhibited any behaviors in the past year or more. The RN UM stated on the last psychiatric consult visit dated 7/22/11 the Psychiatrist recommended a merrywalker for the resident's restlessness. In addition, the RN UM explained the resident's Plan of Care was reviewed at the Interdisciplinary Team (IDT) meeting held on 9/13/11 and stated they did not review the resident's Seroquel or Ativan. The RN UM further stated there were no care plan revisions for this resident since 8/8/10 when the resident was assessed and issued a merrywalker and that she needs to review the resident's Plan of Care to revise it for appropriate interventions.

Review of the facility policy entitled Care Planning, with a revision date of 10/11, revealed the Nurse Manager will prepare for the Care Plan meeting. The Nurse Manager reviews and updates the MDS, assesses and observes the resident and discusses problems and needs with the staff. Each discipline is responsible for making appropriate care approaches and short and long term measurable goals.

415.11(c)(2)(iii)

Based on observation, record review and staff interview, the facility did not ensure that each resident receives adequate supervision and assistance devices to prevent accidents. One (Resident #126) of four residents reviewed for accidents had an issue that involved the transportation of a resident by being pulled backwards in a shower chair with the bottom of both bare feet and heels dragging. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #126 has diagnoses of diabetes mellitus, multiple sclerosis, peripheral neuropathy (disorder affecting a number of nerves), osteoporosis, peripheral vascular disease (PVD - poor circulation of lower extremities), and chronic leg swelling. Review of the Minimum Data Set (MDS) dated 7/29/11 revealed the resident understands and is understood, and is totally dependent on staff for locomotion on the unit.

Review of the Comprehensive Care Plan (CCP) last updated 10/11 identified the resident as non-ambulatory and wheelchair dependent. The CCP also identified the resident as having skin that was desensitized to pain and pressure and included that the resident needs to elevate heels off the floor during transport.

On 10/24/11 at 4:00 PM, the resident was observed being transported backward in a shower chair by a Certified Nurse Aide (CNA) in the presence of the Registered Nurse (RN) Unit Manager. During the transport, the resident was noted to be pulled backwards with the bottom of both bare feet and heels dragging on the carpeted rug for approximately 35 feet. At no time did the CNA assist the resident to lift his legs.

When interviewed on 10/25/11 at 1:00 PM, the RN Unit Manager explained that the resident was not able to lift his feet and the CNA involved in the transport was instructed on proper resident transport.

415.12(h)(2)

Based on record review and staff and resident interview, the facility did not develop policies and procedures that ensure that each resident is offered influenza and pneumococcal immunization, unless the immunization is contraindicated or the resident had already been immunized. Two (Residents #195, 214) of five residents reviewed for influenza immunizations did not receive education of the risks and benefits of receiving the influenza vaccine. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #195 has diagnoses including severe peripheral vascular disease and status post bilateral above knee amputations. Review of the Minimum Data Set (MDS) dated 8/16/11 revealed the resident is cognitively intact.

Review of the Immunization Record revealed the resident received the Influenza vaccine on 9/28/11. There was no documented evidence the resident received education regarding the risks and benefits of receiving the vaccine.

On 10/24/11 the resident was interviewed by a Registered Nurse (RN) Nurse Manager (NM) at 2:50 PM in the presence of a surveyor and stated he did not recall being educated regarding the influenza vaccine risks and benefits and has not seen the CDC Vaccine Information Sheet.

none 2. Resident #214 has diagnoses including diabetes mellitus and status post knee amputation of left first and second toes-non healing surgical wound. Review of the Minimum Data Set (MDS) dated 8/16/11 revealed the resident is cognitively intact.

Review of the Immunization Record revealed the resident refused the influenza vaccine on 9/28/11. There was no documented evidence the resident was educated regarding the risks and benefits of receiving the vaccine.

An interview with the Registered Nurse (RN) Nurse Manager (NM) on 10/24/11 at approximately 2:30 PM revealed education was not provided because the resident refused the vaccine.

The RN NM interviewed the resident in the presence of the surveyor on 10/24/11 at 3:15 PM. He stated he did not receive education regarding the risks and benefits of the vaccine. He further stated he had not received the CDC Vaccine Information Statement.

415.19(a)(1)

Based on record review and staff interview, the facility did not ensure that residents are free of any significant medication errors. One (Resident #195) of ten residents reviewed for unnecessary medications had an issue involving a medication not restarted as ordered by the physician. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #195 has diagnoses including severe peripheral vascular disease and status post bilateral above knee amputations.

Review of a Telephone Order dated 9/16/11 revealed a Physician's Order to discontinue Plavix (prevents platelet aggregation) and restart in two weeks if no further nosebleeds. The 9/30/11 Resident Calendar documented "Restart Plavix if no more nosebleeds; see order for 9/16/11". Review of the 10/4/11 Physician's Orders revealed no order for Plavix.

The Progress Note Report printed and submitted to the surveyor on 10/24/11 revealed no Interdisciplinary Notes to reveal the resident as having nosebleeds since 9/16/11.

An interview with the Registered Nurse (RN) Nurse Manager on 10/24/11 at approximately 2:00 PM revealed the follow up had been entered on the calendar and she found no documented evidence the resident had experienced nosebleeds since the Plavix had been discontinued on 9/16/11.

Review of a Medication Error Report dated 10/24/11 revealed the Physician was notified and gave an order to Restart Plavix 75 milligrams (mg) orally daily since nosebleeds have ceased.

Review of a verbal order dated 10/24/11 revealed a Physician's order to restart Plavix 75 mg orally every day.

An interview with the RN Desk Nurse on 10/25/11 at 10:05 AM revealed she entered the follow up in Microsoft Outlook which contains the calendar for the residents. She further stated that she missed it on 9/30/11 when it was due to be restarted.

415.12(m)(2)

Based on observation, record review and staff interview, the services provided or arranged by the facility were not provided by qualified persons in accordance with each resident's written plan of care. One (Resident #126) of one resident observed for transport had an issue involving a transport that was not provided according to the care plan. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #126 has diagnoses of multiple sclerosis, peripheral neuropathy (disorder affecting a number of nerves), peripheral vascular disease (PVD - poor circulation of lower extremities), and chronic leg swelling. Review of the Minimum Data Set (MDS) dated 7/29/11 revealed the resident understands and is understood, and is totally dependent on staff for locomotion on the unit.

Review of the Comprehensive Care Plan (CCP) last updated 10/20/11, revealed the resident as non-ambulatory and wheelchair dependent. The CCP also identified the resident as having skin that was desensitized to pain and pressure including a plan to elevate the resident's heels off the floor during transport.

The resident was observed on 10/24/11 at 4:00 PM being transported backward in a shower chair by a certified nurse aide (CNA) in the presence of the Registered Nurse (RN) Unit Manager. During the transport, the resident was noted to be pulled backwards with the bottom of both feet and heels dragging on the carpeted rug for approximately 35 feet. At no time did the CNA assist the resident to lift his legs.

Interview on 10/25/11 at 1:00 PM with the RN Unit Manager revealed that the resident was not able to lift his feet. In addition, the CNA involved in the transport was instructed on proper resident transport and the importance of following the Care Plan.

415.11(c)(3)(ii)

Based on observation and staff interview during a Life Safety Code survey, means of egress were not continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. This affected three (Basement, First Floor, Second Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 10/18/11 at approximately 11:44 AM revealed an approximate 32 gallon trash receptacle, an approximate two foot wide floor fan and an approximate four foot tall by three foot wide walker were stored in front of and obstructing the path of egress to the B Stairway in the Unit A1 Activities room. Further observation at this time revealed that this room is located near resident room #A137. Continued observation at this time revealed that the B Stairway served the Basement, First and Second Floors.

Observations on 10/21/11 at approximately 10:01 AM and 12:43 PM revealed an approximate 32 gallon trash receptacle, an approximate four foot tall by three foot wide walker and a linen cart were stored in front of and obstructing the path of egress to the B Stairway in the Unit A1 Activities room.

2. Observation in the Basement on 10/18/11 at approximately 1:52 PM revealed that six chairs were stored in the vestibule that makes up part of the exit egress path from the C Stairway to the exterior of the building. Also at this time observation revealed that this vestibule also makes up part of the exit egress pass from the Basement to the exterior of the building. Continued observation at this time revealed that the C Stairway served the Basement, First and Second Floors. Interview with Director of Environmental Services at this time revealed he was not sure why these chairs were stored in the vestibule.

3. Observations on the Second Floor on 10/19/11 at approximately 12:18 PM and 2:23 PM revealed an approximate five foot long by three foot wide cart full of activities supplies was stored in the Unit A2 Activity room obstructing the path of egress to the B Stairway exit door.

4. Observations on the Second Floor on 10/19/11 at approximately 2:22 PM and 3:18 PM revealed a walker, a chair and a clean linen cart were stored in the corridor obstructing the path of egress to the A Stairway exit door.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 7.1.10, 7.1.10.2, 7.1.10.2.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 11/18/10.

Based on observation and staff interview during a Life Safety Code survey, hazardous areas were not properly maintained. Issues included hazardous area walls that were not designed to resist the passage of smoke and hazardous area doors that would not self-close and latch into their frames. This affected three (Basement, First Floor, Second Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 10/18/11 at approximately 9:48 AM revealed an approximate four inch long by two inch wide open, unsealed penetration was observed in one of the interior walls of the Unit A1 Soiled Utility room. Also at this time observation revealed an approximate two inch long by two inch wide open, unsealed penetration was observed in one of the interior walls of the Unit A1 Soiled Utility room. Further observation at this time revealed that these open, unsealed penetrations were observed to be in the wall that separated the Unit A1 Soiled Utility room from the Unit A1 corridor. Continued observation at this time revealed that this room was located near resident room #A155.

2. Observation on the Second Floor on 10/18/11 at approximately 9:55 AM revealed that the door to the Unit B2 Soiled Utility room would not self-close and latch into its frame. Also at this time observation revealed that this door could not be physically latched into its frame. Further observation at this time revealed that this room was located across from the Unit B2 Nurses Station.

3. Observation on the Second Floor on 10/18/11 at approximately 11:09 AM revealed that there was an approximate one inch long by one inch wide open, unsealed penetration in one of the interior walls of the Unit A2 Clean Utility room. Further observation at this time revealed that this Clean Utility room was located near resident room #A255.

4. Observation in the Basement on 10/18/11 at approximately 1:09 PM revealed the door to the West Dietary Storage room would not self-close and latch into its frame. Further observation at this time revealed that part of the door's self-closing mechanism was missing. Interview with the Director of Environmental Services at this time revealed that he was not sure why part of the door's self-closing mechanism was missing.

5. Observation in the Basement on 10/18/11 at approximately 1:34 PM revealed the door to the Laundry Clean Linen room would not self-close and latch into its frame. Further observation at this time revealed that the door's latching mechanism was getting hung-up on the door's catch plate.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA: 19.3.2.1

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEYS COMPLETED ON 11/18/10 and 12/3/09.

Based on observation and staff interview during a Life Safety Code survey, oxygen cylinders and oxygen storage areas were improperly maintained. Issues included an unsecured oxygen cylinder, an oxygen cylinder that was prone to potential mechanical shock, oxygen cylinders that were stored too closely to combustibles, duplex electrical outlets that were installed less than five feet from the floor's surface in oxygen storage areas and an oxygen storage area that lacked signage. This affected two (First Floor, Second Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on the First Floor on 10/18/11 at approximately 9:37 AM revealed that one D sized oxygen cylinder with a regulator attached to it was stored unsecured lying on its side on the counter in the Unit B1 Treatment room. Also at this time observation revealed that the storage of the cylinder in this manner left it prone to mechanical shock if it were to fall off of the counter. Further observation at this time revealed that this cylinder was stored directly against four, 100 count cardboard boxes of vinyl gloves and that this room was used to store medical supplies. Continued observation at this time revealed that this room was not sprinklered and that the room lacked signage that oxygen was being stored within the room.

2. Observation on the First Floor on 10/18/11 at approximately 9:46 AM revealed two E sized oxygen cylinders were stored in the Unit A1 Clean Utility room and that this room had two duplex electrical outlets that were installed less than five feet from the floor's surface. Further observation at this time revealed that this room was located near resident room #A154.

3. Observation on the Second Floor on 10/18/11 at approximately 10:50 AM revealed two E sized oxygen cylinders were stored in the Unit A2 Clean Utility room and that this room had one duplex electrical outlet that was installed less than five feet from the floor's surface. Also at this time observation revealed a trash receptacle partially full of paper napkins, cardboard and foam cups was stored directly against one E sized oxygen cylinder and within eight inches of two other E sized oxygen cylinders. Further observation at this time revealed that this room was located near resident rooms #A216 and #A222. Interview with the Director of Environmental Services revealed that the facility staff had previously been told not to store combustibles within five feet of the oxygen cylinders.

4. Observation on the Second Floor on 10/18/11 at approximately 11:09 AM revealed one E sized oxygen cylinder was stored in the Unit A2 Clean Utility room and that this room had two duplex electrical outlets that were installed less than five feet from the floor's surface. Also at this time observation revealed that a linen cart full of clean towels and gowns was stored less than two inches from an E sized oxygen cylinder. Further observation at this time revealed a 15 ounce aerosol can of flammable disinfection spray that lacked a lid was stored on a linen cart within two feet of an E sized oxygen cylinder. Continued observation at this time revealed the word flammable was written after the physical and chemical hazards label on the can and that this room was located near resident room #A255.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
1999 NFPA 99: 8-3.1.11.2(c)1, 8-3.1.11.2(c)2, 8-3.1.11.2(f),
4-3.1.1.2(a)11d, 8-3.1.11.2(g), 4-3.5.2.1(b)13, 8-3.1.11.2(h), 4-3.5.2.1(b)(27), 8-3.1.11.3, 4-3.1.1.2

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 11/18/10.

Based on observation, record review and staff interview during a Life Safety Code survey, one of one Basement Laundry Dryer access room and one of one Laundry room were not maintained to minimize the possibility of a fire emergency requiring the evacuation of occupants. Issues included excessive amounts of lint and/or dust on the sides of dryers, on a wall, on the tops of piping and ventilation ducts as well as on the floor between the dryers and on top of part of the dryer's lint collection system. This affected one (Basement) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation in the Basement on 10/18/11 at approximately 1:36 PM in the Laundry Dryer access room revealed the top of part of the dryer's lint collection system was covered with an approximate one half inch layer of lint and/or dust. Also observation revealed an approximate seven inch long by five inch wide by one half inch thick layer of lint and/or dust was removed from the top of part of the dryer's lint collection system.

2. Observation in the Basement on 10/18/11 at approximately 1:38 PM in the Laundry room revealed that the sides of five dryers were covered with an approximate one eighth inch thick layer of lint and/or dust. Also at this time observation revealed that the wall to the left of one of the dryers was covered with an approximate one eighth inch thick layer of lint and/or dust. Further observation at this time revealed that five approximately five foot long by five inch wide areas of the floor between the dryers was covered with an approximate one quarter inch thick layer of lint and/or dust. Continued observation at this time revealed that the tops of the ventilation ducts and piping in the Laundry room were covered with an approximate one quarter to one half inch thick layer of lint and/or dust.

Interview with the Director of Environmental Services and the Environmental Services Secretary on 10/19/11 at approximately 2:00 PM revealed that the Laundry staff empties the lint collector every other day and that there was a log sheet for this in the Laundry room. Continued interview with the Director of Environmental Services and the Environmental Services Secretary at this time revealed that Laundry staff were supposed to be cleaning the sides of dryers, on the tops of piping and ventilation ducts, the floor between the dryers, the walls near the dryers and on top of the dryer's lint collection system but that the staff must not have been cleaning these areas. Review of the Lint Collection Log on 10/19/11 at approximately 2:09 PM revealed that the lint collector had been cleaned every other day from 9/12/11 through 9/18/11 and that the log showed no information for the cleaning of the sides of dryers, on the tops of piping and ventilation ducts, the floor between the dryers or on top of the dryer's lint collection system.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 19.1.1.3

Based on observation and staff interview during a Life Safety Code survey, sprinklers were covered with excessive amounts of lint and/or dust. This affected three (Basement, First Floor, Second Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation in the Basement on 10/18/11 at approximately 1:40 PM revealed four sprinklers were covered with excessive amounts of lint and/or dust in the Laundry room. Interview with the Director of Environmental Services at this time revealed the sprinkler heads should not have been covered with lint.

2. Observations on the Second Floor on 8/19/11 between the hours of 12:23 PM and 12:36 PM revealed automatic sprinkler heads located in the A2 unit corridors near resident rooms #A215, #A225, #A231, #A255, #A273 and #A276 were covered with excessive amounts of dust. Also at this time observation revealed that these sprinkler heads were located near vents from the ventilation system.

3. Observations on the First Floor on 8/19/11 between the hours of 12:36 PM and 12:47 PM revealed automatic sprinkler heads located in the Unit A1 corridors near resident rooms #A127, #A131, #A137 and #A171 were covered with excessive amounts of dust. Also at this time observation revealed that these sprinkler heads were located near vents from the ventilation system.

Interview with the Director of Environmental Services and the Administrator on 10/20/11 at approximately 3:45 PM revealed that the outside vendor that inspected and tested the facility's automatic sprinkler system was supposed to have cleaned the sprinkler heads.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 9.7.5
1998 NFPA 25: 2-2, 2-2.1, 2-2.1.1

Based on observation and staff interview during a Life Safety Code survey, stairways were being used as storage areas. This affected three (Basement, First Floor, Second Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 10/18/11 at approximately 11:50 AM revealed four approximately three foot tall by four foot long by four foot wide tables, one approximately three foot tall by six foot long by three foot wide gurney and one approximately five foot tall by four foot long by three foot wide clothing rack were stored in the B Stairway on the Basement level. Also at this time observation revealed that the B Stairway serviced the Basement, First and Second Floors. Interview with the Director of Environmental Services at this time revealed that the tables, the gurney and the clothing rack had been stored in the stairway for approximately one week.

Observations on 10/19/11 at approximately 2:18 PM and on 10/20/11 at approximately 8:48 AM revealed one approximately three foot tall by six foot long by three foot wide gurney and one approximately five foot tall by four foot long by three foot wide clothing rack were stored in the B Stairway on the Basement level.

2. Observation on 10/18/11 at approximately 1:55 PM revealed an approximate four foot tall by five foot long by two foot wide construction cabinet, an approximate three foot tall by two foot long by one foot wide construction cart and an approximate 32 gallon trash receptacle were stored in the C Stairway on the Basement level. Also at this time observation revealed that the C Stairway served the Basement, First and Second Floors. Interview with the Director of Environmental Services at this time revealed that this equipment belonged to an outside vendor that was working in the facility and that he was not aware that the vendor was storing their equipment in the stairway.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 7.2, 7.2.2.5.3, 7.1.3.2.3

THIS IS A REPEAT DEFICIENCY FROM THE STANDARD SURVEY COMPLETED ON 11/18/10.

Based on observation and staff interview during a Life Safety Code survey, manual fire alarm pull stations were obstructed. This affected two (Basement, First Floor) of three resident use floors. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation in the Basement on 10/18/11 at approximately 1:50 PM revealed a two-wheeled hand cart was stored directly in front of and obstructing the fire alarm pull station located in the Boiler room.

2. Observation in the Basement on 10/18/11 at approximately 1:51 PM revealed a floor buffing machine, an approximate 44 gallon trash receptacle and an approximate 32 gallon trash receptacle were stored in front of and obstructing the manual fire alarm pull station in the loading dock located near the Emergency Generator room. Interview with the Director of Environmental Services at this time revealed that the manual fire alarm pull station should not have been obstructed.

3. Observation in the Basement on 10/20/11 at approximately 8:53 AM revealed a partially full, approximately 55 gallon trash receptacle was stored in front of and obstructing the manual fire alarm pull station in the loading dock located near the Kitchen.

4. Observation on the First Floor on Unit B1 on 10/20/11 at approximately 8:56 AM revealed a mechanical lift was stored in front of and obstructing the manual fire alarm pull station located near resident room #B121.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
2000 NFPA 101: 9.6.1.4
1999 NFPA 72: 2-8, 2-8.2, 2-8.2.1