Isabella Geriatric Center Inc

Based on observation, record review and resident and staff interviews, the facility did not ensure that medically related social services were provided to meet the resident's highest practicable physical, mental and psychological well-being. Specifically, for a married couple who requested to share a room together. This was evident for one 1 (one) of 30 (thirty) sampled residents. (Resident # 20).

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

The finding is:

Resident #20 is a an 83 year old male admitted to facility on 7/9/09 with diagnoses which include: Anxiety, Depression, End Stage Renal Disease and Congestive Heart Failure.

The Minimum Data Set 3.0 Assessment ( MDS) dated 11/20/10 documented that the resident has some memory problems with modified decision making skills.

On 1/20/11 at 10:50 A.M. the Resident was observed lying in bed speaking Spanish to a female visitor.

On 1/20/11 at 11:30 A.M. the Resident was interviewed and stated that he is very upset that his requests to room with his wife have not been responded to by staff. He further stated that he and his wife have been married for 62 years and his wife has to visit him in his room.
The Resident's wife was sitting in the room at the time of the interview and speaks very little English.

The Social Worker Notes and Comprehensive Care Plan (CCP) from 1/2010 through 1/20/2011 were reviewed. There is no documented evidence that the facility offered the married couple a shared room.

On 1/20/11 at approximately 1:15 P.M., the Registered Nurse was interviewed and stated that she was aware that the Resident wished to room with his wife. She further stated that she referred this to the social worker.

On 1/20/11 at 12:45 P.M., the Resident's social worker was interviewed and stated that Resident's daughter requested that her parents not be placed in the same room. The Social Worker further stated that he was aware of resident's request but followed the wishes of the daughter.

On 1/20/11 at approximately 1:45 P.M., the Community Director for the 4 House Unit was interviewed and stated that she recalls the resident speaking to her about wanting to share a room with his wife but that their daughter wanted them separated. She further stated that this took place sometime in September of 2009.

The Resident's wife was interviewed on 1/20/11 at 2:30 P.M. with an Spanish speaking interpreter and she stated that she very much wants to room with her husband. She further stated that she hopes she will not have to wait much longer because she misses being with her husband.

415.5(g)(1)(i-xv)

Based on observation, record review and resident and staff interviews, the facility did not ensure that the rights of a married couple were honored. Specifically, for a married couple who requested to share a room together. This was evident for one 1 (one) of 30 (thirty) sampled residents. (Resident # 20).

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

The finding is:

Resident #20 is a an 83 year old male admitted to facility on 7/9/09 with diagnoses which include: Anxiety, Depression, End Stage Renal Disease and Congestive Heart Failure.

The Minimum Data Set 3.0 Assessment ( MDS) dated 11/20/10 documented that the resident has some memory problems with modified decision making skills.

On 1/20/11 at 10:50 A.M. the Resident was observed lying in bed speaking Spanish to a female visitor.

On 1/20/11 at 11:30 A.M. the Resident was interviewed and stated that he is very upset that his requests to room with his wife have not been responded to by staff. He further stated that he and his wife have been married for 62 years and his wife has to visit him in his room.
The Resident's wife was sitting in the room at the time of the interview and speaks very little English.

The Social Worker Notes and Comprehensive Care Plan (CCP) from 1/2010 through 1/20/2011 were reviewed. There is no documented evidence that the facility offered the married couple a shared room.

On 1/20/11 at approximately 1:15 P.M., the Registered Nurse was interviewed and stated that she was aware that the Resident wished to room with his wife. She further stated that she referred this to the social worker.

On 1/20/11 at 12:45 P.M., the Resident's social worker was interviewed and stated that Resident's daughter requested that her parents not be placed in the same room. The Social Worker further stated that he was aware of resident's request but followed the wishes of the daughter.

On 1/20/11 at approximately 1:45 P.M., the Community Director for the 4 House Unit was interviewed and stated that she recalls the resident speaking to her about wanting to share a room with his wife but that their daughter wanted them separated. She further stated that this took place sometime in September of 2009.

The Resident's wife was interviewed on 1/20/11 at 2:30 P.M. with an Spanish speaking interpreter and she stated that she wants to room with her husband. She further stated that she hopes she will not have to wait much longer because she misses being with her husband.

415.(f)(3)

NFPA 99 Section 16-3.11
Nursing homes shall comply with the provisions of Chapter 11 for emergency preparedness planning, as appropriate.

11-5.3.9* Drills.
Each organizational entity shall implement one or more specific responses of the emergency preparedness plan at least semi-annually. At least one semi-annual drill shall rehearse mass casualty response for health care facilities with emergency services, disaster receiving stations, or both.

Based on record review and interview, it was determined that the facility did not ensure that disaster drills are conducted at least semi-annually. This is evidenced by only one disaster drill being conducted within a calendar year. This has a potential of affecting the entire facility.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

The review of the facility disaster drill logs on 1/19/11 between 12:00pm and 3:00pm revealed that only one disaster drill was conducted in 2010 (on 9/29/10).

In an interview with the Safety and Security Director on 1/19/11 at approximately 1:40pm, she stated that they conducted one disaster drill in 2010 and that she will ensure that drills are conducted at least semi annually hence forth.

415.26(f) (1)
711.2(a) (26) NFPA 99 Section 16-3.11

Based on observation and interview, it was determined that not all sprinkler control valves were supervised so as to sound at least a local alarm when the valve is closed. This was observed in Sprinkler room located on the basement of 515 building.

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

The Findings is:

From 01/14/11 thru 01/19/11 an Annual life safety inspection was conducted. It was observed that in 515 building two (2) sprinkler valves in the basement were not electronically supervised.

In an interview with the Director of Maintenance, he stated that the valves control the standpipe and that the building is equipped with gravity tanks. He further stated that these valves will be electronically supervised.

NYCRR 711.2(a)(1); LSC 19.3.5.1; 9.7.2.1

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 electrically operated main exit/entrance sliding doors in lobby section of building 525 is maintained to push open in emergency with only one releasing operation and that the latch releasing device provided at the door is a familiar latch releasing device which could be operated in all lighting conditions.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the LSC inspection conducted on 1/19/11 between 10:00am and 3:00pm, it was observed that the electrically operated main exit/entrance sliding doors in the lobby section of building 525 is designed to be pushed open in emergency and had an inscription " In Emergency Push to Open " . It was also observed that the door is provided with a locking device which is operable with a thumb twist latch/lock releasing device. When the locking device is engaged, the door cannot be pushed opened manually, as designed. The releasing of the locking device and then pushing the door open would require multiple door releasing operations. Also, the thumb twist latch/lock releasing device provided at the door is not a familiar latch releasing device which could be operated even during darkness. The egress doors cannot have a locking device which would impede the free releasing of the door in an emergency.

In an interview with the Director of Facilities Management on 1/19/11 at approximately 12:30pm, he stated that the thumb latch device was installed for security reasons and that the front desk is a 24 hr manned location.

711.2(a)

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.

K 038 S/S=B
NFPA 101, 19.2.1, 7.1
The wall mounted televisions in the resident rooms in building #525 provide less than 6' ft 8"inches head clearance.

Based on observation and interview, the facility did not ensure that exit components are enclosed with construction having a fire resistive rating of at least one hour in that cable wires penetrated and passed completely through the firewall in central stairwell in building 525. This was observed in the third floor stairwell.

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

The Finding is:

From 01/14/11 thru 01/19/11 an Annual Life Safety evaluation of the facility was conducted. It was observed that building 525 had eleven (11) resident floors and partially sprinklered.

Evaluation of the central stairwell revealed that on the third floor landing area a metal box was observed on the wall below the ceiling area. In discussion with the Director of Engineering and Associate Administrator they stated that this box serves as transfer point of cables and that only company(timewarner) can access this metal box was. Also, it was not clear what the fire rating of the metal box was. All penetrations into the exit stairwell are prohibited except that which serves the stairwell.

In an interview with facilities managment, they stated that the code does allow electrical penetrations into the stairwell. The facilty must ensure that all stairwells are protected from unnecessary penetrations.

[42CFR 483.70(a); 2000 LSC: 19.3.1.1, 8.2.5.2; 10NYCRR 415.29(a)(2), 711.2(a)(1

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):
LSC 19.3.7.3

K 25 S/S=B
Smoke barriers are not continuous, as these are penetrated by common ducts from toilet rooms on either side of the smoke barriers.