NY Congregational Nursing Center, Inc

Based on observation and interview it was determined that the facility did not ensure that the garbage compactor located in the rear yard of the building was equipped with a lid that was lockable to prevent pest movement and to assure proper disposal.

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

The findings are:

During the annual life safety and environmental survey on 4/5/10, it was noted that at approximately 12:45 p.m., the compactor which was located in the rear yard of the facility was equipped with a gate/door that is required to keep the compactor shut when not in use. The top hinge of the door to the compactor was broken off and the door could not be properly closed.
In an interview with the Executive Director Of Facilities Management at the same time, he stated that a few days earlier, the hinges broke and he called the company responsible for maintaining the compactor and reported that the gate/door was broken and the representative from the company stated that they would send someone to do the repairs as soon as possible. He further stated that he would place a call to the company again to expedite the process of fixing the gate/door.

483.35 (I) (3)

Based on record review and staff interview, the facility did not ensure that a physician's order for blood sugar monitoring was consistently implemented. This was evident for one (1) of thirty (30) sampled residents. (Resident #5)

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

The finding is:

Resident #5 is 43 year old with diagnoses which include Diabetes Mellitus, Status Post Percutaneous Endoscopic Gastrostomy (tube inserted into stomach), Hypertension, and Cerebrovascular Accident.

The Minimum Data Set (MDS) 2.0 assessment dated 2/2/2010 documented the resident with short and long term memory impairments, severely impaired cognition, and totally dependent on staff for feeding via the feeding tube.

The Physician's monthly order dated 3/16/2010 documented "Finger sticks AM (in the morning) & (and) PM (at afternoon) every Mondy (Monday) & (and) Thursdy (Thursday), twice week inform MD (Medical Doctor) if B.S. (blood sugar) < 70 or >300 (below 70 or above 300)."

The Medication Administration Record (MAR) dated 3/17/2010 to 4/6/2010 documented the finger stick was to be done at 6 AM and 5 PM. There was no documented evidence that the finger stick was done on 3/22/2010, 3/25/2010, and 4/5/2010 at 5 PM as per physician's order.

On 4/6/2010 at 4:40 p.m., the Licensed Practical Nurse at evening shift was interviewed and stated he did not do the implement finger stick. The nurse stated he did not realize he did not do thee finger sticks at 5 PM.

415.11 (c)(3)(ii)

(2). Section 7.2.1.3 Floor Level.

The elevation of the floor surfaces on both sides of a door shall not vary by more than 1/2 in. (1.3 cm). The elevation shall be maintained on both sides of the doorway for a distance not less than the width of the widest leaf. Thresholds at doorways shall not exceed 1/2 in. (1.3 cm) in height. Raised thresholds and floor level changes in excess of 1/4 in. (0.64 cm) at doorways shall be beveled with a slope not steeper than 1 in 2.

Based on observation and interview, it was determined that the facility exit discharge from stairwell " B " has a "drop off" of 6 inches after the designated emergency exit landing. A drop off of this magnitude will interfere with the safe movement of the occupants of the building in case of fire or other emergency.

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

The findings include:
On 4/5/10, at approximately 12:30 PM, it was observed that the exit discharge at the exterior of exit stair 'B' from the facility to Parking lot and towards the main entrance/exit has a 6-inch "drop off" at the end of the exterior landing. The "drop off" of the floor surfaces on both sides of a door shall not vary by more than 1/2 in. (1.3 cm). The presence of such a "drop off" present a safety hazard to the occupants using the exit in case of fire or other emergency.
On 4/5/10, at approximately 12:40 p.m., the facility Executive Director of Facility Management stated that constructing a ramp could eliminate the drop off, and he would immediately bring this to the attention of the Administrator.

711.2 (a)(1)

Based on observation and interview, it was determined that the facility did not maintain the smoke barrier wall with at least a one half-hour fire resistance rating. The deficient practice was evident on one (1) of six (6) units in the facility.

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

The findings include:

On 4/5/10 during the annual Life safety code survey the following was observed: at approximately 10:30 a.m. a tile of the suspended ceiling at the smoke barrier wall above the smoke barrier doors, which are adjacent to the dining room on the second floor resident unit was removed by the Executive Director of Facilities Management for inspection. An unsealed penetration of about 4 x 4 inches, through which a bundle of wires was passed, was noted. The hole was not sealed with fire resistance material that will prevent smoke from passing through.

In an interview with the Executive Director of Facility management on 4/5/10 at approximately 11:00 a.m., he stated that the facility upgraded the telephone system about 8 months ago and the company was supposed to have sealed all penetrations but must have missed this one. He however stated that this penetration would be sealed with UL listed fire rated material immediately.