Wayne Center for Nursing & Rehabilitation

Based on observations,records review, and interviews the facility did not ensure that the food items were stored, prepared and distributed under sanitary conditions to prevent food borne illness, as evidenced by: 1) Card board box containing bread slices, stored as delivered in kitchen reach in refrigerator 2) Tube feed spike kit boxes were placed on floor in the store room 3) Cold food items on tray line did not meet temperature guidelines 4) Sanitizer solution in pot washing sink did not meet the required concentration when tested. These had the potential to affect the entire facility.

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

The findings are :

1) On 8/22/11 at 9:50 AM during the initial tour of the kitchen, observed inside the refrigerator, referred to as 'Pantry reach in refrigerator', 4 boxes of individually wrapped bread slices in a card board box stored, as delivered from truck.

On 8/22/11 at 9:55 AM the Food service Director (FSD) was interviewed and stated that the bread slices should have been unpacked and placed in a clean bin instead of directly from the loading doc to refrigerator as this was a potential for contamination.

2) On 8/22/11 at 10:15 AM there was observed on the floor in the dry store room, 2 boxes of Enteral delivery system, 'spike right kits' which are used to connect tube feedings.

On 8/22/11 at 10:20 AM the store room staff member was interviewed and stated that he had placed the spike kits on a pallet and not on the floor but the Dietician may have been the person who did.

On 8/22/11 at 10 :25 AM the FSD stated that he could not explain why the dietitian would have placed the boxes on floor, when they were on a pallet to start with.

On 8/22/11 at 10:45 AM the Dietitian who prepared the tube feeding supplies, stated that all supplies, including the spike kits boxes were on a pallet and she set up all the supplies for the Food service Worker (FSW) to take to floors, however the cart was full, these two boxes were too big and so she had placed them on the floor. She admitted that she should have left the boxes on the pallet, instead of on the floor; She further stated that all boxes are usually stored on pallets to protect them from bugs and water damage.

3) On 8/23/11 at 11:45 AM tray line cold food temperatures were observed in Kitchen as
follows:
Pureed Three bean salad 70 degrees Farenheit (F)
Regular Jello 60 F degrees
Pureed Jello 50 F degrees
Apple Juice 50 F degrees
Cold foods temperatures did not meet the guidelines of 40 F degrees or below.
A pan of salad was also observed on the counter near the trayline, from which the salads were portioned out. The pureed three bean salad pan was placed on ice in a pan, with only the bottom of the pureed salad pan touching the ice.
On 8/23/11 at 11:55 AM the FSD was interviewed and stated that the whole pureed bean salad pan needed too be covered with ice to maintain cold temperature. He further stated that the cold foods should be kept in the refrigerator prior to service.

4) On 8/23/11 at 12:05 AM observed the Pot Washing area. The FSW, while demonstrating the testing procedure, immersed the test strip for one second and checked against the color code. It did not match the color for the recommended 200 Parts per million (PPM). The FSW was immediately interviewed and stated that he should dip the test strip for 10 seconds and match the color. He was asked how long he leaves the pots and pans in sanitizing solution, and responded that he leaves the pans for 20 seconds.
On 8/23/11 at 12:10 PM the Food service Director (FSD) was interviewed and stated that the FSW is new and he will inservice him on pot washing and testing procedure.
The instructions printed on the pHydrion test kit documents to immerse the test strip for 10 seconds and to match the color to 200 PPM
The instructions posted above the pot washing area documents to immerse the pots and pans for 2 minutes in sanitizing solution.
415.14(h)

Based on observations, records review, and staff interviews the facility did not ensure that the residents received services in the facility with reasonable accommodations of individual needs and preferences as evidenced by: 1) Resident was observed wearing a pair of leather shoes with no socks or shoe laces and the resident did not have any change of clothing available in his closet.
2) the facility did not ensure that a legally blind resident with desire to read was provided with appropriate adaptive devices and materials for reading.
This was evident for 2 of 22 residents reviewed for significant care concerns. (Residents # 179 and # 260)
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are :

1) Resident # 179 was admitted on 9/10/2007 with diagnoses of Senile dementia of Vascular type, Psychosis, Hypertension and Hyperlipidemia.

On 8/23/11 at 9:30 AM the resident was observed in the main dining room (MDR) neatly dressed and groomed, except for the shoes without shoe laces that he was observed wearing on his bare feet.

On 8/24/11 at 12:15 the resident was observed in bed in his room. The resident's shoes were observed on the floor by the bed, and no socks or shoe laces were noted with them.

The Minimum Data Set (MDS) 3.0 annual assessment dated 7/15/11 documented: Brief interview of mental status (BIMS) score 15, hearing, speech and vision adequate, rejects care (1 to 3 days), has strong preference to choose his own clothes for wear, all activities of daily living (ADL) (ambulation, transfer, eating and loco on /off unit) done with supervision and requires limited assist for dressing and personal hygiene.

A Comprehensive Care Plan (CCP) dated 8/12/10 and revised on 4/27/11 documented that the resident has vascular dementia, independent for most ADL with supervision, and needs extensive assist of one with dressing and personal hygiene.

A review of the medical record revealed no personal property list of clothing or other belongings.

Social Services interim assessment dated 7/14/11 documented : "Resident for Physical and functional status partially dependent; resist care, orientation and Long term/Short Term (ST/LT) memory and judgement intact."

Social services annual assessment dated 7/14/11 documented : "Res continue to resist taking showers, and changing clothes; no family."

The Certified Nursing Assistant (CNA) accountability sheet for August, 2011 documented: "Resident has impaired cognition and LT/ST memory problem; Resident dresses himself with supervision and independent for ambulation".

On 8/24/11 at 12:45 PM the day shift assigned CNA was interviewed and stated that the resident is very independent for all ADL, including dressing and showering. He just asks for, and gets the needed supplies. She further stated that the resident wears what he likes, and if he is given a suggestion of what to wear he becomes agitated.

On 8/24/11 at 12:50 PM the resident's closet was inspected with a CNA. There was only one shirt and a jacket in the closet. The CNA expressed surprise that the closet was almost empty and stated that additional clothing may have been placed in the laundry basket. There was no laundry basket observed in the resident's room or bathroom.

On 8/24/11 at 1:00 PM the Registered Nurse (RN) was interviewed and stated that upon inquiry the resident told her he did not bring any clothes on admission (in 2007). She further stated that the resident takes showers but does not change his clothes because he did not want to wear donated clothes.

On 8/24/11 at 1:15 PM, the Social Worker was interviewed and stated that she does not look into residents' closets anytime regarding clothes, unless informed by the CNA of the need for it. She further stated that no one informed Social Services about the resident's needs for clothes. She stated that she had observed the resident wearing his same jacket all the time, but never looked at his feet to see if he wears socks or shoe lace.

On 8/25/11 at 9:35 AM the resident was interviewed and stated that he has only one good shirt and no pants; no clothes to change. He further stated that the shoe laces broke a long time back and staff told him to go to the 2nd floor and get one but none were available.

2) Resident # 260 is a 60 year old admitted to the facility on 5/11/2011 with diagnoses which include Legal Blindness, Asthma , Hypertension, and Depression.

The Minimum Data Set (MDS) 3.0 assessment dated 6/20/2011 documented that the resident has intact memory and cognition; impaired vision (sees large print, but not regular print in newspaper/books) with use of glasses; and in the Interview for Activity Preferences the resident stated it was "very important" to her to have books, newspapers, and magazines to read.

During individual interviews with the resident on 8/22/2011 at 1:13 PM and on 8/25/2011 at 10:45 AM, the resident stated that she is legally blind with no vision to her right eye and decreased vision in her left eye due to cataract. The resident further stated that she enjoys reading, and can read regular print with glasses for a very brief period of time, however if she reads longer her eye hurts and she is afraid to strain it. The resident said that prior to residing in the facility she used a "talking book machine" from the library for the blind, however she currently has no one who could bring the machine to the facility. The resident stated she spoke with the Social Worker (SW) a couple of weeks after she came in about her desire to read and was provided with one audio tape (which she showed to the surveyor), but not with the device to play the tape. The SW told her she had difficulty getting the player. The resident states she would be happy with the books on tape from any public library. "I don't understand why is this so difficult. I am not the only person here with impaired sight." The resident could not recall if she initially spoke with anyone from the Therapeutic Recreation (TR) Department about her need for adaptive equipment for reading and stated she mentioned to different staff she needed a tape player, but was told the facility had none. The resident could not recall the names of staff she spoke with, except for the SW.

The Optometry consult dated 6/9/2011 documented "Vision without glasses R (right) NLP (no light perception), L (left) 20/400, cornea scarred over OD (right eye), retinal scars OS (left eye) Pseudophakia OS (left eye)".

Activities/recreation therapy full admission assessment dated 5/24/2011 documents "Past interests/Hobbies: reading, socializing, music, Current Interests/Hobbies: same ...vision: impaired, legally blind".

The Therapeutic Recreation (TR) Comprehensive Care Plan dated 5/24/2011 includes intervention as: provide activity calendar, encourage participation in scheduled group activities, encourage independent decision making regarding recreation involvement.

The intervention related to reading or provision of reading materials/adaptive devices (except for glasses) was not documented in the resident's TR or Vision comprehensive care plan.

There is no documented evidence in the Social Work documentation related to provision of reading materials or special adaptive devices, books on tapes, or similar.

On 8/25/2011 at 11:54 AM the Director of Therapeutic Recreation (TR) was interviewed and stated he completed initial assessment, which included the resident interview and at that time he pointed out to the resident that the regular and large print books were available in the facility, but did not discuss with the resident use of the tape players or books on tape and did not specifically care plan for reading. The Director continued stating that he would have ensured that the resident was provided with needed devices and reading materials if the resident's desire was communicated to him.

On 8/25/2011 at 12:40 PM the Social Worker (SW) was interviewed and stated that the Social Worker assigned to the resident is currently on vacation. The SW stated that routinely a resident with visual impairment and interest in reading would have been provided appropriate reading materials and adaptive equipment in collaboration with the TR department.

On 8/25/2011 at 1 PM the Social Work consultant was interviewed by phone stated she provides oversight to the Social Workers and visits the facility 1-2 times per week, also she is available to assist by phone any time during the work week. The Consultant stated that the resident with visual impairment and love for reading could improve her highest practicable quality of life if assisted with obtaining appropriate reading materials like large print books, books on tape, or other appropriate adaptive equipment. It is responsibility of a Social Worker to work with the TR staff to provide what is needed.

415.5 (e)(1)

Based on observations, records review, and interviews the facility did not
provide medically-related social services to attain or maintain the highest practicable physical, mental, and psychosocial well-being of each resident. This was evidenced by a resident that was observed wearing a pair of leather shoes with no socks or shoe laces. Also the resident did not have any change of clothing available in his closet. This was noted for one resident in a sample of 40 resident census samples observed. Resident # 179

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

The finding is:

Resident # 179 was admitted on 9/10/2007 with diagnoses of Senile dementia of Vascular type, Psychosis, Hypertension and Hyperlipidemia.

On 8/23/11 at 9:30 AM the resident was observed in the main dining room (MDR) neatly dressed and groomed, except for the shoes without shoe laces that he was observed wearing on his bare feet.

On 8/24/11 at 12:15 PM the resident was observed in bed in his room. The resident's shoes were observed on the floor by the bed, and no socks or shoe laces noted with it.

The Minimum Data Set (MDS) 3.0 annual assessment dated 7/15/11 documented: Brief interview of mental status (BIMS) score 15, hearing, speech and vision adequate, rejects care (1 to 3 days), has strong preference to choose his own clothes for wear, all activities of daily living (ADL) (ambulation, transfer, eating and loco on /off unit) done with supervision and requires limited assist for dressing and personal hygiene.

A Comprehensive care plan (CCP) dated 8/12/10 and revised on 4/27/11 documented that the resident has vascular dementia, independent for most ADL with supervision, and needs extensive assist of one with dressing and personal hygiene.

A review of the medical record revealed no personal property list of clothing or other belongings.

Social Services interim assessment dated 7/14/11 documented : "Resident for Physical and functional status partially dependent; resist care, orientation and Long term/Short Term (ST/LT) memory and judgement intact."

Social services annual assessment dated 7/14/11 documented : "Res continue to resist taking showers, and changing clothes; no family."

The Certified Nursing Assistant (CNA) accountability sheet for August, 2011 documented: "Resident has impaired cognition and LT/ST memory problem; Resident dresses himself with supervision and independent for ambulation".

On 8/24/11 at 12:45 PM the day shift assigned CNA was interviewed and stated that the resident is very independent for all ADLs, including dressing and shower; He just asks for, and gets the needed supplies. She further stated that the resident wears what he likes, and if he is given a suggestion of what to wear he becomes agitated.

On 8/24/11 at 12:50 PM the resident's closet was inspected with a CNA. There was only one shirt and a jacket in the closet. The CNA expressed surprise that the closet was almost empty and stated that additional clothing may have been placed in the laundry basket. There was no laundry basket observed in the resident's room or bathroom.

On 8/24/11 at 1:00 PM the Registered Nurse (RN) was interviewed and stated that upon inquiry the resident told her he did not bring any clothes on admission (in 2007). She further stated that resident takes showers but does not change his clothes because he did not want to wear donated clothes.

On 8/24/11 at 1:15 PM, the Social Worker was interviewed and stated that she does not look into residents' closets anytime regarding clothes, unless informed by the CNA of the need for it. She further stated that no one informed Social Services about the resident's needs for clothes. She stated that she had observed resident wearing his same jacket all the time, but never looked at his feet to see if he wears socks or shoe lace. The Social Worker also stated that the resident gets a monthly allowance but keeps a very low balance (now 0.35 cents) because he smokes heavily and uses most of his money for cigarettes.

On 8/25/11 at 9:35 AM the resident was interviewed and stated that, he has only one good shirt and no pants; no clothes to change. He further stated that the shoe laces broke a long time back and staff told him to go to the 2nd floor and get one but none were available.

415.5 (g)(1)

Based on observations and interviews the facility did not ensure that refuse and garbage was disposed of properly. This was observed at the dumpster area, outside the building.

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

The findings is:

On 8/22/11 at 10:35 AM the garbage disposal process was observed from Kitchen to dumpster area, out side of the building. The garbage cans from the kitchen were transported with closed lids to the outside area. There were 6 small size dumpsters, all open and uncovered, with garbage up to one fourth to one half level in all the dumpsters. There were several yellow bumble bees hovering over the garbage dumpsters.

On 8/22/11 at 10:55 AM the House keeping Director was interviewed and stated that all dumpsters have to be closed with a lid . He further stated that they all had lids but that they may have been taken off for cleaning.

A second observation of the dumpster area was made on 8/22/11 at 11: 30 AM . 4 of the 6 dumpsters were covered with the flip type lids, one dumpster was half covered with a dented lid that did not fit tightly and one dumpster had no lid.

On 8/23/11 at 12:15 PM the dumpster area was again observed. Four of the dumpsters were covered , one was half covered since the lid was broken, and the 6th dumpster was open, with card board boxes.

415.14 (h)

Based on resident and staff interviews and record review the facility did not ensure that the residents received mail from the postal service on Saturday. This was evidenced by the facility arranging with the postal service to hold mail delivery to the facility on Saturdays for delivery on Monday. This had the potential to affect the entire facility.

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

The finding is:

On 8/24/11 at approximately 10:45 AM the President of the Resident Council was interviewed. She stated that the residents do not receive mail on Saturdays and that the residents were never provided an explanation why they do not receive mail on Saturdays. She stated that the people from recreation usually deliver the mail to the residents during the week.

On 8/25/11 at 2:11 PM the Director of Recreation was interviewed. He stated that his department sorts and delivers the residents mail. They deliver the mail Monday through Friday. There is no delivery of mail on Saturdays, because he was told by the executive office staff that the post office does not deliver mail to the facility on Saturdays. He stated that recreation staff is onsite at facility on Saturday and Sunday.

On 8/25/11 at 2:17 PM the Executive Secretary was interviewed. She stated that mail service was halted on weekends at the request of the facility. The facility made the request to the post office to hold mail until Monday. The mail is then delivered to the residents on Monday. She stated that this decision was made a few months ago, because there was no staff on weekends (Executive) to receive and separate the facility mail from the resident's mail. She does this task during the week and does not work on the weekends.

On 8/25/11 at 2:45 PM the Administrator was interviewed. She stated that she is aware of this issue. This policy predates her tenure as administrator at the facility approximately one year ago.. She stated that the owners of the facility made the decision to hold weekend mail delivery and that she was aware of the regulations ensuring resident's right to receive mail on weekends.

There was no documented evidence that the residents were consulted regarding the halting of mail delivery on the weekends.

The Policy and Procedures were reviewed. It directs that residents should receive mail unopened and within 24 hours of delivery.

415.3(d)(2)(i)

Based on record review and staff interview, the facility did not ensure the surety bond equaled or exceeded the total amount of the residents' funds to assure security of all the residents' funds deposited with the facility. This resulted in a pattern with no actual harm and potential for minimal harm.

The Finding is:

The resident's funds balance was reviewed on 8/25/2011 and revealed a balance of $151, 858.70.

The bond for the Residents' Personal Funds Trust Fund, purchased on February 24, 2011, for period of 12 months was reviewed on 8/25/2011 and revealed a limit of $146,000.00.

On 8/25/2011 at 3:15 PM the Director of Finances was interviewed and stated that it was his responsibility to purchase and to maintain adequate coverage of the surety bond. The Director stated that he checked the total amount of the Residents Personal Funds on a regular basis. He further stated that the last time he checked it was July 2011 and it did not exceed the bond limit then.

415.25 (h)(5)(v)

Based on observation, record review, resident and staff interview, the facility did not ensure that a resident's grievance regarding missing clothing was resolved. This was evident for 1 of 22 residents reviewed for significant care concerns (Resident # 260). This resulted in no actual harm with potential for minimal harm.

The finding is:

Resident # 260 is a 60 year old with diagnoses which include Asthma, Legal Blindness, Hypertension, and Depression.

The Minimum Data Set (MDS) 3.0 assessment dated 6/20/2011 documented the resident's memory and cognition as intact.

During individual interviews with the resident on 8/22/2011 at 1:13 PM and on 8/25/2011 at 11 AM, the resident stated that her black sweatshirt top with a hood was missing for more than a month. The resident stated she reported a missing item to "the person who delivers the laundry", but "she never got back to me ... ".

The Certified Nursing Assistant (CNA) responsible for clothing was interviewed on 8/26/2011 at 11:20 AM and stated that routinely dirty clothes are collected in individual laundry bags and sent out for washing to the outside provider every Monday, Wednesday, and Friday. After the laundry bags are returned to the facility, the CNA stated, she opens them, places clothes on hangers and delivers them to the residents' rooms. If the resident reports to her missing clothing item she calls the laundry provider to inquire about the missing item and they usually call her back within a few days. If the laundry provider reports that the item was not found, the CNA reports the missing item to the Administrator, who then gives her approval to replace the missing item. The CNA stated she recalled the resident reported her missing clothing item "about 2-3 weeks ago" and she reported it to the laundry company representative, but did not hear from him since. The CNA stated that she does not reports missing clothing items to the Social Worker and does not maintain a tracking system of the missing items reported by the residents, therefore there is no documentation to verify when the resident reported the missing item or when the laundry provider was contacted.

The Administrator was interviewed on 8/25/2011 at 1:56 PM and stated that the CNA responsible for clothing usually reports all missing clothing items, which are then replaced with authorization from the Administration. The Administrator stated that the CNA should receive the response from the laundry company representative within 2-3 days and if the item is confirmed missing, the CNA should report to her, so that the item could be replaced. The Administrator stated she was not aware of the resident's missing sweatshirt top and that there should be a tracking system in place to assure that search for all reported missing clothing items is timely conducted and resolved.

415.3 (c)(1)(ii)

Based on observation, resident and staff interviews, the facility did not ensure that the residents with personal funds in the facility were made aware of how to access their funds on the weekends. This was evident for 4 of 4 residents reviewed for personal funds. (Residents # 45, # 112, # 260, and # 420) This resulted in no actual harm with the potential for minimal harm.

The Finding is:

During individual interviews with Residents # 45, # 112, # 260, and # 420 on 8/22/2011 and 8/23/2011, the residents stated they maintain personal accounts in the facility and that the facility's banking days are on Mondays and Fridays. The residents further stated that they can access their funds on remaining days of the week per request, but not on the weekend.

Observations of the bulletin boards on the 6th and 4th floor revealed "Petty cash policy" notices which documented that resident's funds are available in the recreation area on Monday through Friday starting at 10:15 AM. "For amounts greater than $50.00 please see your social worker ... ".

Review of the Resident Council meeting minutes for period February - July of 2001 reveals " petty cash distribution is in the recreation area (Monday & Friday between 10:30- 11:00), except on emergency basis.. ".

The Social Worker was interviewed on 8/25/2011 at 1:50 PM and stated that the Social Workers are not in the facility on the weekends and the residents routinely make withdrawals on Fridays to cover their monetary needs for the coming weekend.

T he Administrator was interviewed on 8/25/2011 at 2:10 PM and stated that the residents can make petty cash withdrawals on the weekend from the therapeutic recreation staff or the nursing supervisors and they were notified during Resident Council meetings and by their Social Workers.

The Director of Therapeutic Recreation was interviewed on 8/25/2011 at 2:15 PM and stated that he was never provided with petty cash funds for the resident's withdrawals on the weekend, nor was this discussed during the Resident Council meetings.

The Director of Nursing was interviewed on 8/45/2011 at 2:20 PM and stated that a $ 200.00 petty cash fund is made available to the nursing supervisors on the weekend for the residents and that this is communicated to the residents upon admission and by the social workers.

415.3 (e)(2)(iii)

Based on observations on the facility did not ensure that residents window blinds were in good repair. As evidenced by broken and missing blinds in residents' room windows. This was evident for 2 out of 40 census sample resident rooms observed. (Rooms #501 and 504).

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

The findings are:

Observations on 8/22/11at 12:54PM in room # 504, and 8/23/11 at 11:42M in room 501, and 8/25/11 at 3:00PM revealed that the blinds in resident's rooms were in disrepair as evidenced by missing and broken blinds.

On 8/25/11 @ 3:17 PM the Director of Maintenance was interviewed. He stated that the facility is in the process of replacing all vertical blinds in the facility with horizontal blinds. This started approximately 3 to 4 months ago. The second, third and fourth floors have been completed. The timetable for completion is by the end of September.

415.5(h)(2)

Section 4-4.3, NFPA10, Standard for Portable Fire Extinguishers states that every 6 years stored pressure fire extinguishers that require a 12-year hydrostatic test shall be emptied and subjected to applicable maintenance procedures. The removal of agent from halon agent fire extinguishers shall only be done using listed halon closed recovery system. When the applicable maintenance procedures are performed during periodic recharging or hydrostatic testing, the 6-year requirement shall begin from that date.

This standard is not met as evidenced by:
Based on observation and review of facility's maintenance record, it was determined that the facility did not ensure that stored-pressure chemical extinguishers provided at different locations in the facility are subjected to maintenance procedures and records maintained in accordance with 4-4.3 and 4-4.4 of NFPA 10, 1998. Reference is made to the stored pressure chemical extinguisher by room #'s 726 and room #605.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On August 22,2011 at 9:30 AM to 2:30 PM it was observed that the stored pressure chemical extinguishers located adjacent to room #'s 726 and 605 on resident floors and the main dining room were hydrostatically tested in May 2004. The extinguishers have not been subjected to the 6 - year maintenance procedures since 2004, as per 4-4.3 and records maintained on a suitable tag or label securely attached to the extinguisher as per 4-4.4. On August 22, 2011, at approximately 11:00 AM the facility's director of maintenance stated that the fire extinguisher company will be contacted to update the maintenance records for all fire extinguishers.

711.2 (a)(1)

Section 7.1.5, NFPA101 states that means of egress shall be designed and maintained to provide headroom as provided in other sections of this code and shall be not less than 7 ft 6 inch (2.3m) with projections from the ceiling not less than 6 ft 8 inch (2m) nominal height above the finished floor. The minimum ceiling height shall be maintained for not less than two-thirds of the ceiling area of any room or space, provided the ceiling height of remaining ceiling area is not less than 6 ft 8 in. (2m) and shall be measured vertically above a plane parallel to and tangent with the most forward projection of the stair tread.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the door opening to the diapers' storage room in the basement was provided with the minimum height of 6 ft 8 inch.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On August 22 , 2011 at 9:30 AM to 2:00 PM, it was observed that the door to the diapers storage room in the basement was only 6 ft 2 inch in height. A minimum headroom clearance required is 6 ft 8 inches. On August 22, 2011, at approximately 1:00 PM, the facility's director of maintenance stated that a full size door will be installed to the diapers' storage room so as to provide the minimum headroom of 6 ft 8 inches.

711.2 (a)(1)

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that the door to the
storage room off exit stair "E" is made self-closing or automatic closing and the door is constructed to resist the passage of smoke.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On August 22, 2011 , at 9:30 AM to 2:00 PM, it was observed that the storage room located off exit stair "E" is protected with automatic extinguishing system (sprinkler system). The door to the storage room lacks self-closing or automatic closing mechanism. The door also had an approximately 2 inch diameter hole in it which will allow the passage of smoke into the stairway. The doors to the sprinklered hazardous areas (storage rooms) are to be constructed to resist the passage of smoke. On August 22, 2011 at approximately 12:00 PM, the facility's director of maintenance stated that the door will be equipped with self-closing device and the hole in the door will be sealed.

711.2 (a)(1)

Section 5.2.1.1.1, NFPA25, requires that sprinklers shall not show signs of leakage, shall be free of corrosion, foreign material, paint, and physical damage; and shall be installed in the proper orientation (e.g. upright, pendent, side wall).

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that sprinklers
installed in the storage room off exit stair "E", were in the proper orientation. Reference is made to the two sprinklers heads which were installed in the upright position whereas, the sprinklers are designed for the pendent position.

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

The findings include:
On August 22, 2011 at 9:30 AM to 2:00 PM, it was observed that at least two sprinkler heads located within the storage room off exit stair "E" were installed in the upright position. These sprinkler heads were, however, constructed for the pendent position instead of the upright type. The sprinkler deflectors were not designed to spray water in a downward pattern. On August 22, 2011 at approximately 11:30 AM, the facility's director of maintenance stated that the sprinkler company will be contacted to correct the orientation of the sprinklers in the storage room.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that exit stair "'C" enclosure is free from the passage of the vertical drain pipe, as per LSC 7.1.3.2.1 and 7.1.3.2.3 .

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On August 22, 2011, at 9:30 AM to 2:00 PM, it was observed that the enclosure to exit stair "C" at the middle landing between the basement and the first floor is penetrated by the vertical drainage pipe of approximately 4 inch diameter . The drainage pipe is not meant to serve the stair enclosure and lacks an enclosure of at least 1-hour fire resistance rating. Any accidental water leakage from the drain pipe in the exit stair would interfere with the safe usage of the stairways by the building occupants during fire or other emergency. On August 22, 2011 at approximately 12:15 PM, the facility's director of maintenance stated that the drainage pipes penetrating exit stair "C" enclosure will be enclosed with at least 1 hour fire resistance rating construction.

711.2 (a)(1)

Physical Plant Violation - State Only

(g) Nurse's calling system shall comply with the following:
(1) A call button shall be provided at each resident bedside, which calls to the nurse's station. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the patients' door, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at the corridor intersections. In rooms containing two or more calling stations, and remain lighted as long as the voice circuit is operating.

This requirement is not met as evidenced by:

Based on observation, and testing of the nurses' call system, it was determined that the facility did not ensure that the call registering stations located within the soiled workrooms and the nourishment stations, on the nursing units are maintained to activate a visible signal when the calls are placed from the resident areas.

The findings include:
On August 22, 2011, at 9:30 M to 2:30 PM, it was observed that the facility installed the call registering stations in the soiled workrooms and the nourishment stations of the nursing units. Nevertheless, the visible signals were not activated in the soiled workrooms and the nourishment station of the nursing units when the calls were placed from the residents' bedside or the toilet rooms during the testing of the call system. Examples are: the soiled workrooms on the 5th, 4th, 3rd and 2nd floor; and the nourishment stations on the 4th floor, 3rd floor and 2nd floors. On August 22, 2011, at approximately 12:30 PM, the facility's director of maintenance stated that the electrical company will be contacted to replace the burnt out bulbs and repair the call registering stations in the required areas so as to activate visible signals in these areas upon placing calls from the resident areas.

713-2.22 (g)(1)