Crown Nursing & Rehab Center

Based on observations and staff interviews, it was determined that the facility did not ensure that food was stored, prepared, distributed and served under sanitary conditions. Reference is made to:
1) Dusty mechanical exhaust vents.
2) Dusty fan in the food preparation section.
3) Water hose in the pot washing section noted to leak.
4) Ice cream reach in freezers were observed with ice built up in them.
5) Low sanitizer concentration noted in the three compartment sink.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the annual inspection conducted on 8/18/10 between 9:00 a.m. and 12:00 p.m. the following was observed in the kitchen section:
1) The mechanical exhaust vents in the dish washing section and by the three compartment sink were observed encrusted with dust.
2) The fan in the food preparation section was noted dusty.
3) The water hose (used for sanitizing carts) in the pot washing section was observed to be leaking.
4) Two ice cream reach in freezers were noted with ice built up.
In an interview with the Food Service Director on 08/18/10 at approximately 10:10am, she stated that all these issues noted would be promptly taken care of.

5) Upon inspection, it was observed that the sanitizer used in the three compartment sink is SAN-IT. When the concentration was tested by the kitchen pot washing staff and the Food Service Director it was observed to be 100ppm. The manufacturer recommends a concentration of at least 200ppm for sanitization purposes.
In an interview with the Food Service Director that same day at approximately 11:45pm, she stated that she would have the pot washing staff prepare a new solution of sanitizer that will meet the required concentration.

415.14(h)

Based on observation, record review and staff interviews, the facility did not ensure that Emergency Medications were replaced prior to the expiration date. This was evident for one (1) of five Resident Care Units( 4th floor).

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

The finding is:

During an initial tour of the 4th floor on 08/18/10 at 9:30 AM Floor/Unit, the "Emergency Box Master List" documented "Dextrose Injectable Syringe containing 50% 25 milligrams per milliliters" expired on 06/30/10.

The Licensed Practical Nurse (LPN) was immediately interviewed and stated that nurses usually do not check this box and it is the Pharmacist who checks for expired medications.

A review of the "Emergency Box Master List" which was attached to the outside of the ER Box and covered with a clear plastic sleeve, documented that on 07/15/10 the Pharmacist checked the Box.

On 08/18/10 at 2:05 PM the Director of Nursing was interviewed and she stated that she expects that the nurses check the ER Box as a part of their routine daily checks.

On 08/18/10 at 2:20 PM, the Pharmacy Manager was interviewed and stated the pharmacist should have removed the expired Dextrose Injectable Syringe on 07/15/10 and that it is the responsibility of the pharmacist to check for medications due to expire within 60 days and replace them.

415.18(a)

Based on observation, record review and staff interviews, it was determined that the facility did not ensure a resident with a history of severe hearing impairment received follow up treatment for hearing services. This was evident for one (1) of twenty six (26) sampled residents. (Resident #11)

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

The finding is:

Resident #11 is a 95 year old male with diagnoses which include Diabetes Mellitus and Chronic Renal Failure.

The Minimum Data Set 2.0 assessment dated 11/11/09 documented that the resident has modified independence in decision making with short term memory problems. It further documented that this resident has highly impaired hearing and uses a hearing aid as a communication device.

The resident was observed on 8/19/10 at 7:35 AM in the dining room eating breakfast independently. During conversation, the resident pointed to his ears and stated he could not hear what was being said. The resident was observed not to be wearing any hearing aids.

The resident was again observed on 8/23/10 at 2:10 PM in the dining room engaged in an arts and crafts activity. He was observed not to be wearing hearing aides.

An ENT (Ear, Nose and Throat) Consult Report dated 9/15/09 documented that the resident complained of decreased hearing and had moderate to severe hearing loss bilaterally. The consult recommended hearing aids after medical clearance.

The Nursing Progress Note dated 9/15/09 documented "...Resident returned to facility approx (approximately) 11:45 AM, new order=Audiology consult..."

A physician's order dated 9/15/09 documented "Audiology Consult."

The revised Comprehensive Care Plan for hearing deficit dated 8/20/10 documented "Resident continues to use hearing aid, plan of care continues."

On 8/19/10 at approximately 7:45 AM, the Registered Charge Nurse was interviewed and stated that the resident does not have nor does he wear any hearing aids.

On 8/23/10 at 1:00 PM, the Registered Nursing Supervisor was interviewed and stated that the resident is hard of hearing and he had hearing aids before but there were lost in the facility since 7/19/09.

On 8/23/10 at 1:50 PM, the Director of Nursing was interviewed and stated that if a resident loses their hearing aid, the resident would be seen by ENT and cleared for audiology. She further stated that the resident would then be scheduled for hearing aid fitting and this process would then take about 3 months. She also stated that this should have been done.

During an interview with the resident on 8/23/10 at 2:10 PM, he complained that he could not hear what was being said. He further stated that his hearing aid was lost in the facility.

On 8/23/10 at 2:20 PM, the Certified Nursing Assistant was interviewed and stated that she informed the charge nurse and other staff members that resident has difficulty hearing. She also stated that she knew the resident had hearing aids at one time but they were lost in the facility.

On 8/23/10 at 3:13 PM, the Social worker was interviewed and stated that she was not aware that the resident lost any hearing aids.

There was no documented evidence that the resident received the necessary follow up services for hearing loss.

415.12(b)

Based on record review and staff interviews, the facility did not ensure that physician's orders were followed for a resident on hemodialysis with orders to hold hypertensive medications on dialysis days. This was evident for one (1) of twenty six (26) sampled residents. (Resident #17)

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

The finding is:

Resident #17 is a 78-year-old with diagnoses which include End Stage Renal Disease (on Hemodialysis) and Hypertension.

The Minimum Data Set 2.0 (MDS) assessment dated 6/26/10 documented that the resident had short and long-term memory problems and moderately impaired cognition.

The Physician's Orders dated 7/20/10 and 8/17/10 documented the following:
(1) "Metoprolol Tartrate 50 mg (milligram) Tab...Give 1 Tablet (50 mg) by oral route daily...Dx: (diagnosis) Benign Hypertension", (2) Vasotec 5 mg Tab...give 1 tablet (5 mg) by oral route once daily...Dx: Benign Hypertension," and (3) "Please Hold Hypertensive Meds on Dialysis Days."

The Nursing Notes dated 8/4/10, 8/11/10, 8/13/10, and 8/20/10 documented that the resident received dialysis on those days.

The Medication Administration Record (MAR) for August 2010 documented that Metoprolol Tartrate and Vasotec were administered on 8/4/10, 8/11/10, 8/13/10, and 8/20/20.

The Registered Nurse (RN) who administered the medications on those dates was interviewed on 8/23/10 at 1:40 PM. The RN stated that she is aware that the resident should not receive hypertensive medications on dialysis days. She further stated that she probably made an error when completing the MAR, marking that the medication was administered instead of not administered. The RN also added that she should have reconciled the MAR to make sure she did not make any errors.

The RN Supervisor was interviewed on 8/23/10 at 2:28 PM. The RN Supervisor stated that he reviews the MARs twice per week for administration errors. He further stated that he would usually notice an error like a medication being administered when it should be held.

415.11(c)(3)(ii)

Based on observation, it was determined that the facility did not ensure that the directional indicator is provided on the perpendicular exit signs erected infront of the exit stairway doors, on resident floors.

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 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility has installed exit signs perpendicular to the direction of travel infront of the exit stairway doors on resident floors. A directional indicator (directional arrow) is lacking on the illuminated exit signs that point to the exit doors. Without the directional indicator signs, the adjacent door to the stair door could be mistaken as the exit stair door. On August 18,2010, at approximately 1:00 PM, the facility's director of maintenance stated that the directional indicators are being placed on all exit stair signs.

711.2 (a)(1)

Section 5-2, NFPA10, Standard for Portable Fire Extinguishers, states that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calender year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that stored - pressure water type portable fire extinguishers located adjacent to room's #314 and 217, are hydrostatically retested at 5 years intervals, as per Table 5-2, NFPA10.

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 18, 2010 at 9:30 AM to 2:00 PM, it was observed that the facility has provided pressure water type portable fire extinguishers in the facility. The fire extinguishers lack the hydrostatic test record to show that the extinguishers are hydrostatically tested at 5 years intervals. At least 2 extinguishers, adjacent to room #314 and 217, were last tested on 6/2005 and 6/2006, respectively). Stored -pressure water type extinguishers must be retested hydrostatically every 5 years and test record be maintained on a suitable metallic label affixed to the extinguisher shell, as per 5-6.4, NFPA10. On August 18, 2010, at approximately 2:00 PM, the facility director's of maintenance stated that the extinguishers with expired test dates are being replaced with new extinguishers.

711.2 (a)(1)

Based on observation and review of facility maintenance records, it was determined that the facility did not ensure that the facility's smoke detectors are tested and records maintained to show that the smoke detectors are within their listed and marked sensitivity range, as per NFPA72.

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 18, 2010 at 9:30 AM to 2:00 PM, it was observed that the facility has installed smoke detectors in resident rooms and in the corridors. Although, the smoke detectors are tested functionally and test records are maintained, the detectors are not being tested for their sensitivity. The smoke detectors must be tested to determine that the detectors are within their marked and listed sensitivity range and records be maintained for such tests as per NFPA72. On August 18, 2010, at approximately 1:30 PM, the facility's director of maintenance stated that the facility will contact the contracted company responsible for the testing of the smoke detectors to obtain the sensitivity test records, if available or will advise the company to perform such testing of the smoke detectors.

711.2 (a)(1)

Based on observation, it ws determined that the facility did not ensure that the corridor walls enclosing the large nursing office are, on the first floor, are free of transfer grilles (ventilation louvers) opening onto he exit corridor/exit lobby, in accordance with 19.3.6.4.

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 18, 2010, at 9:30 AM to 2:00 PM, it was observed that enclosure corridor wall to the large nursing office, on the first floor, is equipped with transfer grilles (ventilating louvers). The presence of these transfer grilles in the exterior /exit lobby walls would allow the penetration of smoke/fire from the office area to the exit lobby/exit corridor, exit corridor walls cannot be equipped transfer grilles(ventilating louvers). On August 18, 2010, at approximately 11:45 AM, the facility director of maintenance stated that the transfer grilles will be sealed to prevent penetration of smoke into the exit lobby.

711.2 (a)(1)

Based upon observation and staff interview, it was determined that the facility did not ensure that one (1) of three (3) facility elevators was equipped with the fire fighters service phase I and fire fighters service phase II recall systems in accordance with ASME/ANSI A 17.3. This was evidenced by the elevator not being equipped with the smoke detector automatic recall and the elevator machine room lacking smoke detector.
This resulted in no actual harm but with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the life safety code inspection conducted on 08/18/10 between 9:00 AM and 3:00 PM it was observed that the facility is a six story building with a basement and is serviced by three elevators. It was also observed that one facility elevator (designated as the kitchen elevator), which travels from the basement through to the 6th floor was not equipped with the smoke detector automatic recall. Furthermore, the elevator machine room for this elevator lacked smoke detector.

In an interview with the Director of Engineering on that same day at approximately 12:55pm, he stated that it was not a passenger elevator and that the elevator company that equipped the other two elevators with the elevator recall said that this one elevator did not need to be equipped with the smoke detector automatic recall since it was designated as the kitchen elevator. He added that if the elevator is required to be equipped with the smoke detector automatic recall and the elevator machine room smoke detector the facility will ensure that it is done.

711.2 (a) (1)

Section 7.2.1.5.4 states that a latch or other fastening device on a door shall be provided with a releasing device having an obvious method of operation and that is readily operated under all lighting conditions. The releasing mechanism for any latch shall be located not less than 34 inches (86 cm) and not more than 48 inches (122 cm), above the finished floor. Doors shall be operable with not more than one releasing operation.

Based on observation, it was determined that the facility did not ensure that the egress doors (from the kitchen section located in the basement and the storage room on the 5th floor), are free from door fastening devices which would require more than one releasing operation, and that the door fastening devices provided at the doors are the familiar type devices with an obvious method of operation under all lighting conditions.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include:

During the LSC inspection conducted on 08/18/10 between 9:00am and 3:00pm, it was observed that the main (egress) door from the kitchen section and the doors to the storage room on the 5th floor by room 516 were equipped with dead bolt type locking device in addition to the conventional door knob type latching device. These door fastening devices, if engaged, would required more than one door releasing operation from the egress side of the room (the releasing of the dead bolt lock using the thumb-twist type releasing device and turning the door knob to release the regular latching device). Furthermore, the thumb-twist type lock releasing device is not a familiar type device which would be readily operated under all lighting conditions.

In an interview with the Director of Housekeeping on that same day at approximately 2:05pm, he stated that the dead bolt type locking device would be removed from the doors noted immediately.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the illumination of exit discharge from the north exit stair is arranged so as to provide continuous lighting upon failure/burning out any single lighting fixture/bulb.

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 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the exit discharge from the North exit stair is illuminated with a single lighting fixture containing one bulb. Multiple lighting fixtures or a lighting fixture containing multiple bulbs must be installed at all exit discharges. This would ensure the continuous illumination of the exit discharge area upon failure/burning out of any single lighting fixture or any single bulb in a fixture. On August 18, 2010, at approximately 1:30 PM, the facility's director of maintenance stated that either multiple lighting fixtures or the lighting fixture with multiple bulbs will be installed at all exit discharges.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the storage location for the oxygen cylinders is kept free of combustible cardboard boxes and other combustible trash, as per 4-3.1.1.2, NFPA99.

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 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the facility is storing oxygen cylinders outside the exit door at the beginning of the exit ramp in the basement. A large open container ( 3 ft x 3 ft x 3 ft), on wheels filled with cardboard boxes, and trash was noted stored at the same location adjacent to the oxygen cylinders. Oxygen storage must be separated from combustible storage, in accordance with NFPA99. On August 18, 2010, at approximately 11: 30 AM, the facility director of maintenance stated that the container containing cardboard boxes was immediately removed from the oxygen storage location and the staff is instructed to keep the oxygen storage location free of combustible storage.

711.2 (a)(1)

NFPA99 Section 11-5.3.5* Logistics.
Contingency planning for disasters shall include as a minimum stockpiling or ensuring immediate or at least uninterrupted access to critical materials such as the following:

(a) Pharmaceuticals
(b) Medical supplies
(c) Food supplies
(d) Linen supplies
(e) Industrial and potable (drinking) waters

Based on observation and staff interview it was determined that the facility did not ensure that stockpiling of emergency food supply was maintained to provide an uninterrupted supply.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the recertification survey on 8/18/10 between 9:00am and 12:00pm, an inspection of the location designated for the storage of emergency food supply revealed that there were only nine 5lbs cans of peanut butter, a case of sardine and a case of 300 two count packs of crackers (this case was already opened and was being used. The facility maintains a three-day emergency food menu and has a bed capacity of 189 beds.

In an interview with the Director of Food services on that same day at approximately 10:20am, she pointed out that she had two unopened cases of cereal for emergency purposes that were stored in the food main storage room. She stated that other items for emergency purposes were also stored in the room where the regular food supply is kept and that she will relocate some of the items from the regular food supply location to the room designated for emergency food storage.

NFPA 101-2000
711.2(a)(26)

Physical Plant Violation - State Only

NYCRR 713-1.18(d)(2)(i): Outdoor air intakes shall be located as far as practical but not less than 25 feet from exhaust outlets of ventilating systems, combustion equipment stacks, medical-surgical vacuum systems, plumbing vent stacks, or from areas which may collect vehicular exhaust and other noxious fumes. The bottom of outdoor air intakes serving central systems shall be located as high as practical but not less than six feet above ground level or if installed above the roof, three feet above roof level.

This requirement is not met as evidenced by:
On August 18, 2010, at 9:30 AM to 2:00 PM, it was observed that the fac ility did not ensure that the air handling equipment, serving the lobby areas, is installed so as the air intake louvers are a minimum of 6 feet above the patio ground level and that the exhaust ventilation fan is a minimum of 25 feet from the air intake louvers.

The findings are:
On August 18, 2010, at 9:30 AM to 2:00 PM, it was observe that the facility has installed a n air handling equipment (air supply unit) for the lobby area on the patio adjacent to the facility building. The patio is used for smoking residents, and can collect smoke. The bott om of the air intake louvers for the air supply unit is only 1 1/2 - 2 feet from the patio floor instead of the minimum of 6 feet. The intake louvers must be raised to prevent the recirculation of cigarette smoke in the lobby area. The intake louvers are also located approximately 5 feet from an air exhaust fan instead of the minimum of 25 feet. On August 18, 2010, at approximately 11:00 AM, the facility's director of maintenance stated that the air intake louvers for the air handler will be raised from the patio floor and the exhaust fan will be re-designed to exhaust at an appropriate distance from the air intake louvers.

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver (s) to be continued.

Include your request for renewal of this waiver or plan of correction in the space provided on this form.

42 CFR 483.70(a):

Life Safety Code 13-2.4.1, 13-2.4.2
On the 6th floor, an exit from the large recreation room (this is a requirement and essential exit designated as West stairs) lead out onto the roof. Then one must traverse about 20 feet on this roof to enter the West stair well. This 20 feet distance on the roof is not protected from the weather elements. It is required to be protected by a roof, to be a straight permanent path, and to be on smooth, solid floors, substantially level. Continuous handrails are also required. Snow, rain etc. must be kept out of this path.

NYCRR 711.2 (a)(1)