Split Rock Rehabilitation and Health Care Center

Based on observations, record reviews and staff interviews, the facility did not ensure that the residents' environment was maintained in good repair as evidenced by: 1) black marks on the handrails and ripped wallpapers above the baseboards through out the unit (Unit 4 South) and 2) multiple nightstand tables in disrepair. This was evident for 1 of six 6 nursing units and 2 of 30 sampled residents. (Unit 4 South and Resident #16 and #18)

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

The findings are:

1) On 4/14/10, during the initial tour of unit 4 South, at approximately 10:15 a.m., the handrails along the walls were observed to have black marks on them and the wallpaper above the baseboards was ripped.

The Registered Nurse Manager was immediately interviewed and stated that she was not aware of when this happened and that normally either housekeeping or maintenance would be notified. She further stated that these departments would be notified by logging the problem in the maintenance log book.

The Director of Maintenance was interviewed on 4/15/10 at 10:20 a.m. and stated that an outside company was working on changing the wires for cable television since the week past and that these black marks were most likely due to the company installing the wires. He further stated that the clothes carts sometimes scrap up against the walls and that causes the wallpaper to be ripped.

The Maintenance Department Complaint Log Sheets dated 10/3/09 through 4/15/10 were reviewed. There was no documented evidence that maintenance was made aware of the handrails and wallpaper.

2) Resident #18 is a 82 year old female with diagnoses which include Huntington's Disease, Chronic Obstructive Pulmonary Disease and Dementia.

The Minimum Data Set (MDS) 2.0 assessment dated 3/12/10 documents short and long term memory loss and severely impaired decision making skills.

On 4/15/10 at approximately 4:00 p.m., the nightstand table in the resident's room was observed to have multiple scratches and worn surfaces. The roommate's nightstand also had multiple scratches and worn surfaces.

Further observations revealed resident rooms 407, 419A, 419B, 425A, 425B, 429C, 429D, 431A, 431D, 435A, 435B, 437A, 437B, 437C, 437D had nightstand tables in disrepair.

The Licensed Practical Nurse (LPN) was interviewed on 4/15/10 at approximately 4:15 p.m. and stated the she was not aware of these nightstands being scratched and worn.

3) Resident #16 is a 93 year old female with diagnoses which include Senile Dementia, Psychotic Disorder and Glaucoma.

The Minimum Data Set (MDS) 2.0 assessment dated 1/29/10 documents short and long term memory loss and moderately impaired decision making skills.

On 4/16/10 at approximately 11:00 a.m., the nightstand table in the resident's room was observed to have multiple scratches, worn surfaces and a door hinge broken.
The resident's roommate nightstand (in bed D) also had multiple scratches and worn surfaces.

The Licensed Practical Nurse (LPN) was interviewed on 4/15/10 at 11:15 a.m. and stated the she was not aware of the marks on these nightstands. She further stated that this is not something she would tend to as this is housekeeping and maintenance's jobs.

The Director of Maintenance was interviewed on 4/16/10 at 5:30 p.m. and stated that he does environmental rounds every 2 weeks to assess resident's furniture and closets. He further stated that he did see 3 resident's nightstands that needed to be repaired and he fixed them but was not aware of the other nightstands.

The Maintenance Department Complaint Log Sheets dated 10/3/09 through 4/16/10 were reviewed. On 11/11/09 at 11:00 p.m., there is documentation that room 413 B nightstand door hanging. There is no further documentation that maintenance was notified of these nightstands in disrepair.

415.5(h)(2)

Based on observations, record reviews and staff interviews, the facility did not ensure that medically related social services were provided to assist residents or their legal representatives in electing advanced directives. This was evident for six (6) of thirty (30) sampled residents. (Residents #1, #13, #15, #16, #17 and #23)

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

The findings are:

1) Resident #1 was admitted to the facility on 1/8/10 with diagnoses including Multiple Sclerosis, Respiratory Failure and Depression.

The Minimum Data Set (MDS) 2.0 assessment dated 1/16/10 documented that the resident had no memory problems and minimally impaired decision-making skills.

The resident was observed in bed on 4/14/10 at 10:15 a.m. She was alert and conversed appropriately. She was again observed on 4/15/10 at 12:30 p.m. in the dining room. She was being fed by a Certified Nursing Assistant (CNA).

The initial Social Service notes on admission to the facility did not document any advance directives education,only that the resident had a guardian. Further review of the record revealed no documented evidence of contact with the guardian prior to 3/8/10. Court guardianship paperwork in the resident's record dated 12/8/2008 documented that she was appointed a guardian who also had decision making power for health care matters. There was no documented evidence that the resident or the guardian was provided education on advance directives.

The resident was interviewed on 4/15/10 at 4:10 p.m. She stated that she was never asked about advance directives and assumed that any thing pertaining to serious life and death decisions would have been discussed with her. The resident acknowledged having a guardian but stated that she thought that was because she was no longer able to take care of her kids.

An interview was conducted with the Director of Social Services on 4/16/10 at approximately 3 p.m. She stated that the resident was able to make decisions but had not been educated on advance directives due to the guardianship. She further stated that the first contact with the guardian was a letter that she mailed out on 3/8/10 which was responded to by them faxing the facility a copy of the papers.

2) Resident #13 is a 86 year old female with diagnoses including Schizophrenia, Dementia and Rheumatoid Arthritis. She has been residing in the facility since 1996.

The Minimum Data Set (MDS) dated 2/10/10 documents that she has long and short memory impairment and has severely impaired decision making.

The resident was observed in her room on 4/15/10 at approximately 3:00 p.m. She appeared alert but confused.

Record review revealed:
An "Advanced Directive Assessment" filed in the resident's chart and dated 11/9/08 documented "Initial discussion with Designated Representative...Will discuss with resident's family regarding Advanced Directive." No election for any kind of directive was documented. The form was signed by the Social Worker.

The Social Work note dated 2/3/09 documented that the Social Worker spoke with daughter about " advanced directives, specifically DNR (Do Not Resuscitate). Resident's daughter not interested."

The Quarterly Review for Advanced Directives dated 2/4/09 documented "Resident's daughter is not interested in executing an an advanced directive."

There is no documented evidence that advanced directives were discussed with the resident's family since February of 2009.

The Director of Social Services was interviewed on 4/15/10 at approximately 4:00 p.m. and stated that the Social Worker who signed the notes is no longer working there. The reviews should be done on a quarterly basis.

3) Resident #16 is a 93 year old female with diagnoses which include Senile Dementia, Psychotic Disorder and Glaucoma.

A Minimum Data Set (MDS) 2.0 assessment dated 1/29/10 documented short and long term memory loss and moderately impaired decision-making skills.

The Social Service Progress Notes dated 5/4/09, 8/6/09, and 11/3/09 were reviewed. There is no documented evidence that advanced directives were updated since 5/4/09.

The Director of Social Services was interviewed on 4/15/10 at 3:30 p.m. and stated that that the social worker who was responsible for this no longer works here and that the new social worker has only been here since March 2010. She further stated she doesn't know what happened.

4) Resident #23 is a 79 year old male admitted to facility on 10/16/09 with diagnoses which include Vascular Dementia, Hypertension and Prostate Cancer.

The Minimum Data Set (MDS) 2.0 dated 1/22/10 documented that the resident has short and long term memory problems and moderately impaired decision making skills.

The Initial Advanced Directive Assessment dated 11/3/09 documented that the resident is unable to educated on Do Not Resituate (DNR) due to mental status.

The Social Work Progress Notes dated 10/16/09, 10/21/09, 11/3/09, 12/24/09 and 1/22/10 did not reveal any documented evidence that advanced directives were discussed with the resident's family or representative.

On 4/19/10 at 10:25 a.m., the Unit Social Worker was interviewed and stated that Advanced Directives are discussed upon admission and quarterly. She also stated that she started working at this facility on 2/22/10 and will update this resident's Advanced Directives on the next quarterly review.

415.5(g)(2)

Based on observations, record reviews and staff interviews, the facility did not ensure that the staff were knowledgeable and competent in maintaining resident safety in the event of an emergency. This was evident by staff responses where staff did not provide appropriate responses regarding emergency preparedness in the ventilator unit, 3-South, 4-North and in 4-South.

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

The findings are:

On 4/15/10 at 4:15 p.m. in 3 south ventilator unit the following was observed: There was flickering of the lights, fire doors closed, and there were no room lights or ventilator screen lights in room 309. The resident's ventilator was quiet and did not have any signs or sounds of being operational. The Respiratory Therapy Director was observed at that time rushing from her office and in a very loud voice instructed all nurses and Certified Nursing Assistants (CNA) to go to the residents' bedside. Several staff members including the Registered Nurse (RN) unit manager were in the proximity of the Director of Respiratory but did not respond until the Director again spoke loudly instructing them to go and check the residents.

Interviews with 1 Licensed Practical Nurse (LPN) in 3 south, 1 LPN in 4 north ,1 LPN in 4 south, 1 CNA and 1 Physical Therapy, on 4/16/10 at approximately 11:30 a.m. The staff provided inappropriate answers on how to respond in an emergency/disaster situation.

The 3 South LPN stated that she received inservices once per year for emergency response. She further stated that she was not sure what to do if the ventilator screen went blank as no one ever told her what that meant.

The 4 North LPN stated that she was employed in the facility only 1 month and believed her responsibility in a power outage would be to check the residents and call the supervisor for further instruction. She also stated that an overhead announcement regarding alarms and generator checks was expected prior to being activated.

The 4 South CNA stated that the facility gave inservices at least monthly but she was not sure what to do except call for help.

The Physical Therapy Aide stated that he was inserviced on fire and external disaster but was not sure about what to do in an emergency as no one clearly told him his role.

On 4/16/10 at 11:37 a.m. the In-service Coordinator was interviewed and stated: "Since 2/2/10 Code D (Disaster), Elopement, Code Blue, Abuse, and Fire drill were provided 2-3 times per week. Power loss in-service was given by the Respiratory Director. Yesterday was the first time we experienced anything like that."

On 4//15/10 at approximately 4:45 p.m., the Respiratory therapy Director was interviewed and stated that she had not been made aware there was a generator test planned and that she became aware of a problem when she lost power to her office computer. She further stated that the screen of the ventilator in room 309 would have gone black due to power interruption after a few seconds. She further stated that the machine should still have been working at the time of surveyor observation, and that the blank screen was a power saving mechanism while the ventilator was on battery power.

On 4//15/10 at approximately 5 p.m., the Maintenance Director was interviewed. He stated that he followed the procedure for notification of the generator load test by notifying the Administration, the switch board and the fire department but had not notified the respiratory department which he stated that he should have done.

415.26(f)(1-3)

Based on observation and staff interview, it was determined that the facility did not ensure that elevator car 2 was maintained to a safe operating condition in that the elevator did not stop on floor indicated.

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

The findings are:

During the annual survey conducted on 04/14/10 and 04/16/10 between 9:00 a.m. and 4:00 p.m., the facility elevator car #2 was noted to malfunction on both days. At approximately 11:00 am on 04/14/10 it was observed that when the elevator was programmed to stop on the 3rd and 4th floors, the elevator bypassed the 3rd floor to the 4th floor but the elevator doors did not open on the 4th floor either. Instead, it went to the 2nd floor and the doors opened. Also, on the same day at approximately 12:45 p.m., when the elevator was engaged to stop on the 4th floor, it traveled to the designated floor but the doors failed to open up again, rather it traveled back to the 1st floor, opened up before going back to the 4th floor. This pattern of malfunction was also noted on 04/16/10.

In an interview with the Director of housekeeping on 04/14/10 at approximately 11:10 a.m., he stated that there has been problems with the elevator in the last couple of days and that the elevator servicing company (PMW) was called in. He further stated that the company said that the problem was with malfunctioning transformers that have to do with the 3rd and 4th floors.

The Director of Housekeeping also presented documentation from the elevator servicing company which showed current visits; however, none of the documents presented indicated that problems with the elevator transformer was an issue that have been addressed.

415.29(b)

Based on observations and staff interviews, the facility did not ensure that acceptable infection control practices were implemented. Specifically, the staff did not store and handle supplies in a manner to prevent the development and transmission of diseases. This was evident for 2 of 6 residents units. (2-South and 4-South)

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

The findings are:

1) During the initial tour of resident unit 2-South, at approximately 10:30 a.m., the Biohazard/Soiled utility Room was observed to contain a box of paper towels in direct contact with the ground. A box of toilet paper was stacked on top on it.

The Housekeeper was in the room at the time and was asked about the the storage of those items. She stated that they were not using items in the bottom box. It was holding up the other.

The Registered Nurse was interviewed at approximately 10:45 a.m. and said that the boxes belonged neither in that room or on the floor.

2) During the initial tour of resident unit 4-South at approximately 10:30 a.m., the Medication Room was observed to have 1 case of plastic gloves, 1 large gift bag with a blue sweater and box of shoes and 1 plastic bag containing a yellow purse on the floor.

The Registered Nurse Manager was interviewed immediately and stated that these items most likely belonged to the staff. She further stated that these items should not be on the floor.

415.19(a)(1-3)

Based on observation and staff interviews, the facility did not ensure that proper security and safeguarding of the controlled medications was maintained. Specifically, the narcotic box was observed to contain controlled drugs and jewelry. This was evident for 1 of 6 units. (Unit 4 South)

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

The finding is:

On 4/14/10 at approximately 10:20 a.m. during the initial tour of 4 South, the narcotic box was observed to have 1 silver ring in a plastic bag labeled; "Found on 4/11/10 by resident's bedside."

The 7-3 shift Licensed Practical Nurse (LPN) was interviewed immediately and stated that the ring is being kept there until the resident's family comes in to identify the ring.

The Registered Nurse Manager was interviewed on 4/14/10 at 10:25 a.m. and stated that they hold and keep any items until the family comes in to identify the item as these residents are confused. She further stated that the ring should not be in the narcotic box.

415.18(d)

Based on observation, record review and resident and staff interviews, the facility did not ensure that a resident is provided the necessary care, services and equipment to attain the highest practicable functioning as evidenced by a resident identified as having a weight problem is consistently weighed, and assessed/evaluated for pain prior to transferring the resident out of bed. This was evident for 1 of 30 sampled resident's. (Resident #3)

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

The finding is:

Resident #3 is a 42 year old male with diagnoses which includes Morbid Obesity, Ventilator dependent, and Lymphedema.

The Minimal Data Set 2.0 (MDS) dated from 6/20/09 to 12/15/09 documented that the resident is independent in cognition and decision making. It further documents for transfer 8/8 (did not occur) and for resident's weight the box was marked with a slash/documented unable to be weighed.

The MDS dated 3/14/10 documented that the resident has modified independence in cognition and decision making. This MDS further documented that the resident was unable to be weighed.

On 4/19/10 at 2:50PM, the resident was observed in bed. The resident stated that he never refused to get out of bed or to be weighed without a reason. He stated that the staff just comes and expects him to "quickly do things." The resident stated that he told them to give him advance notice so that he could get prepared. The resident stated that he told the staff that it is very painful to move and that he needs to be medicated before he is moved. The resident stated that the staff told him that they don't have the proper equipment to get him out of bed. The resident became tearful when he stated that "I would love to come out of bed." Before I gained more weight I use to come out of bed and I was so happy. It would mean so much to me to get out of this bed." The resident further stated that the facility has known about this situation for over 3 years and "nobody did nothing about it."

On 4/19/10 at 3:15PM, it was observed that approximately 6-8 staff members came to assist the resident to be weighed. Immediately following the Social worker informed the surveyor that " He did not want to be weighed now. He just told me his preference of being weighed and getting OOB. He would like these done in the morning and pre-medicated."

The weight/vital signs sheet dated 12/13/07 documented that the residents' height is 5 feet 10 inches and a weight of 680 from the hospital. This sheet further documented that from 1/08 to 9/09, the resident was "Unable to weigh." There is no documented evidence from 10/09 to 4/19/10, that the resident was weighed.

The most recent pain assessment tool dated 2/29/08 documented that the resident has left knee pain that is excruciating and the pain worsens upon positioning, upon movement and upon deep palpitation. This pain is alleviated with immobilization and pain medication. There is no documented evidence of the resident's pain being assessed/evaluated prior to weighing or moving the resident.

The Nutrition Progress Notes dated 6/23/09 documented "...Resident's wt (weight) is not available 2 (secondary to) bariatric scale unable to record resident's wt. Last recorded wt was 2/08 from the hosp (hospital) & (and) he weighed 667.2 lbs. (pounds). Resident was scheduled to be weighed 3/5/09 to try if current wt can be recorded however, resident refused & stated he's in pain. On 2-3 gm (gram) NA (sodium) (low) fat (low) chol (cholesterol) 1800 cal (calorie) diet, non compliant c (with) diet, requesting extra food from staff. Food preferences based on new cycle menus (1 to 4) reviewed c resident & his new food choices incorporated in his diet...6/22/09 ...alb (albumin) 3.2 marginal, the rest acceptable. Continue plan of care."

The physicians' progress note dated 9/14/09 to 4/14/10 did not document any evidence of an evaluation of the resident's pain upon getting out of bed or the difficulty in weighing the resident.

The nutrition progress notes dated 9/22/09 documented "...unable to record resident's weight. Maintained on 2-3 gm Na low fat, low chol 1800 cal rst (restrictive) diet, continues to be non complaint c his diet, calls the Kitchen for extra foods Labs as of 9/16/09 ...alb 2.8 low the rest acceptable Hgb (hemoglobin - range is ) 8.4 low, Hct (hemocrit - range is ) 27.8 low...Will recommend 30 ml Prostat 101 BID (twice a day) 2 hypoalbuminemia. Continue plan of care."

The Nutrition Evaluation/assessment and care plan dated 12/15/09 documented that the resident's weight status was "unable to weigh" with a IBW (Ideal Body Weight) 183 to 198 pounds. This plan further documented "...Estimated Calorie Need: 1800 Cal (BEE (basal energy expenditure) X (times) Activity X Stress) Based Last Wt 2/08...Resident self c 100% meals and fluid. Non-complaint c therapeutic Diet. Tends to call Kitchen For Extra Food Counseling not effective. Unable to obtained Current weight 2 Bariatric Scale indicating Zero (scale not acomondation gross Wt. Lab. Result shows ABM (hypoalbuminemia)..."

The Comprehensive Care Plan for Therapeutic Diet dated 12/15/09 documented to monitor weight as ordered.

The Comprehensive Care Plan for transfers dated 12/24/09 documented that the resident is bedfast and is totally dependent on staff for transfers. The plan further documented that the resident requires hoyer lift and extensive assist of 1 or 2 persons.

The Comprehensive Care Plan for pain management dated 12/24/09 documented that the resident has "discomfort/pain on all or part of the time". The interventions documented were "pain assessment on admission, quarterly & PRN (as needed). Encourage resident to report pain promptly. Observe for non-verbal signs of pain e.g. grimacing, crying, moaning, gasping. guarding, insomnia, restlessness, anxiety, diaphoresis and advice MD. Administer medication as ordered: Percocetq (every) 6 hrs (hours) PRN. Tylenol 650 mg (milligrams) Evaluate effectiveness of medication. Pain management consult PRN. Provide medical management of underlying cause of pain. Identify area of discomfort... Identify factors/conditions which increase and exacerbate pain."

The physicians' orders dated 12/30/09 to 3/24/10 documented that the resident was ordered pain medications of Percocet 5/325 2 tablets by mouth every 8 hours as needed for pain and Tylenol 650mg by mouth every 6 hours as needed.

The Physician Order dated from 12/30/09 to 3/24/10 documented "Out of bed (OOB) to recliner 3X (times) weekly via Hoyer lift w (with)/2 persons assist for transfer....Diet: 2-3 GM (gram) NA (sodium) low fat, low cholesterol, 1800K (calorie) diet-regular consistency..." There is no documented evidence of doctors' orders to weighed the resident.

On 4/19/10 at 11:30AM, the Registered Dietician was interviewed and stated "The last time the resident was weighed was from the hospital 12/13/07 and was 680 pounds. We do not have a scale to weigh him. We got one from the outside and was not able to weigh him. But he can't get OOB I'm assuming he's 800 and something pounds now."

On 4/19/10 at 12PM, the physician was interviewed and stated that he was not aware that the resident was not being weighed. He further stated that he is not aware if the resident has a chair but he can come out of bed if he has a chair to hold his weight and support his legs. He also stated that he just went and spoke to the resident and the resident informed him that all the time he has been saying that it is painful to get out of bed and that he would like to be medicated prior to being weighed.

ON 4/19/10 at 12:50PM, the CNA (Certified Nursing Assistant) was interviewed and stated that from the time she became employed here the resident has been bedfast. She further stated that she has been told the scale cannot work on the resident. She also stated the resident needs more than 3 or 4 staff to assist him.

On 4/19/10 at 3PM the unit RN Supervisor was interviewed and stated that the canvas cannot support the resident weight and the resident would not be safe transferring with this. He further stated that since he came here 5 months ago the resident has been bedfast and that he was not aware of a scale at this facility to hold resident's weight.

On 4/19/10 at 4:30PM the Medical Director was interviewed and stated that the resident's refusal of care was not followed up because he is refusing care just to manipulate the staff.

On 4/19/10 at 5:30PM, the Rehabilitation Director was interviewed and brought a chair which had damaged wear and tear on the arms rests, stating it belongs to the resident and resident was assessed 6 months ago in the chair. He further stated that the chair capacity holds 850 pounds. He then came back at 6:15PM and informed that resident was never assessed in that chair because he refused to be.

415.12

Based on observation and staff interview it was determined that the facility did not ensure that foods were distributed and served under sanitary conditions in that the dish washing machine was not maintained to attain a temperature of 180F (Fahrenheit) which is required for sanitizing purposes.
This resulted in no actual harm with the potential for more than immediate harm that is not immediate jeopardy.

The finding is:

During the annual inspection conducted on 4/16/10 between 9:00 a.m. and 11:00 a.m., the dishwashing machine in the kitchen section was noted to be a high temperature dish washing machine. The dishwashing machine was observed with a final rinse temperature of 150F.
In an interview with the Food Service Director on the same day at approximately 9:55 a.m., he indicated that a back up sanitizer (Eco San liquid sanitizer) was installed in the dish washing machine.

A review of the manufacturer's label on the sanitizer indicates that it is used for sanitizing tablewares in low temperature ware washing machines. Furthermore, the documentation provided by the facility states that "Eco-San is specifically labeled for use as a final rinse sanitizing agent in a low temp dish machine."

415.14(h)

NFPA 101
7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.
(d) * On the door adjacent to the release device, there shall be a readily visible, durable sign in letters not less than 1 in. (2.5 cm) high and not less than 1/8 in. (0.3 cm) in stroke width on a contrasting background that reads as follows:
PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS

Based on observation and interview, it was determined that the exit door leading to the compactor area which is equipped with a delayed egress mechanism did not function when tested.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During the LSC survey conducted on 04/14/10 at approximately 3:05pm, the exit door located in the facility lobby that leads to the compactor area was noted equipped with a delayed egress mechanism. A sign that reads: "PUSH UNTIL ALARM SOUNDS
DOOR CAN BE OPENED IN 15 SECONDS" was also installed. When this door was tested it was observed that the door did not function as designed.

In an interview with the Director of Housekeeping on the same day at approximately 3:40pm, he stated that he cannot tell why the delayed egress mechanism on the door was not functioning. He added that he had not noticed it until during the survey when it is brought to his attention.

711.2 (a)(1)

1999 NFPA 110 Standard for Emergency and Standby Power Systems
6-4 Operational Inspection and Testing
6-4.2*
Generator sets in Level 1 and Level 2 service shall be exercised at least once monthly, for a minimum of 30 minutes, using one of the following methods:
(a) Under operating temperature conditions or at not less than 30 percent of the EPS nameplate rating
(b) Loading that maintains the minimum exhaust gas temperatures as recommended by the manufacturer
The date and time of day for required testing shall be decided by the owner, based on facility operations.

Based on record review and staff interview, it was determined that the facility did not ensure that the emergency generator was exercised under load for 30 minutes on a monthly basis.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

The review of facility maintenance logs on 04/16/10 between 10am and 1:00pm revealed that the emergency generator was not exercised under load at least once monthly. For example the following dates were noted in their log book when the load tests were done: 10/20/09 and 12/2/09 (examples not all inclusive).

In an interview with the Director of Housekeeping on 04/16/10 at approximately 10:30 a.m, he affirmed that the generator was not exercised under load on a monthly interval as observed in the recorded dates. He stated that the specific lapse in time between 10/20/09 and 12/2/09 was because during the period under review there was a transition between himself and the former Director of maintenance.

711.2(a)(1)

Based on observation and interview, it was determined that the facility did not ensure that all hazardous areas are protected as per 19.3.2.1 in that the doors to 3N soiled utility room and the smoking room were not maintained to positively latch and resist the passage of smoke.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

Findings are:

During the LSC survey conducted on 4/14/10 at approximately 11:35am, the door to the 3N soiled utility room was observed equipped with a self-closing device. When tested (released to close) the door did not positively latch. In an interview with the Director of housekeeping at this time, he stated that the facility maintains a weekly schedule of environmental rounds during which doors are checked. He added that the 3N soiled utility room door would be fixed.
Furthermore, on 04/16/10 at approximately 3:20pm, the door to the smoking room located in the facility lobby was also noted equipped with a self-closing device. This door did not latch positively to resist the passage of smoke when tested (released to close). In a concurrent interview, the Director of housekeeping stated that a maintenance staff will be directed to fix the door immediately.

711.2 (a)(1)

Life Safety Code section 19.3.5.1 requires that all health care facilities that are required by section 19.1.6 to have automatic sprinkler protection are protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7.
Section 9.7.1.1 requires that sprinklers be installed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Section 9.7.5 requires that the sprinkler system be maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems.

Based on record reviews and staff interviews during the recertification survey, it was determined that the facility did not ensure that the automatic sprinkler system is maintained, inspected, and tested in accordance with the requirements of NFPA 25. Reference is made to:

1. Lack of documentation to show that the pressure gauges for the sprinkler system were tested (calibrated) and/or replaced within the last five years.
2. Lack of documentation to show that sprinkler test was being performed by personnel who have developed competence through training and experience.

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

The findings were:

During the review of facility's maintenance documentation on 04/16/10 between 9:00am and 12:00pm it was noted that:
1) No documentation was presented to show that the pressure gauges for the sprinkler system were tested (calibrated) and/or replaced within the last five years.
In an interview on the same day at approximately 2:40pm, the Director of housekeeping stated that they were unable to locate documentation to show that the facility's sprinkler pressure gauges were changed. He further stated that he contacted the previous Director of Maintenance, via telephone, who told him that the sprinkler pressure gauges were changed and that the document was somewhere in the office.

2) Since November, 2009, the sprinkler inspection/test was being conducted by a facility staff. As at the time of survey (04/16/10), no documentation was presented to show that the staff conducting inspection/test had developed competence through training and experience. The last sprinkler inspection/test that was conducted by the staff was on 4/6/10.
In an interview on the same day at approximately 2:45pm, the Director of Engineering stated that he usually conducts the sprinkler flow test/inspections but that he had not got a certificate of fitness yet. He added that a company was contracted in March, 2010 that also conducts the flow test.

711.2 (a) (1)