Fairview Nursing Care Center Inc

REPEAT DEFICIENCY
Based on observations and interviews, it was determined that the facility did not ensure that maintenance services necessary to maintain a sanitary and comfortable interior were provided. Reference is made to:
1) Water leakage from the ceiling slab in the main storage room in the basement.
2) Peeling paint and stained ceiling slab observed in the main storage room in the basement.
3) Pipes in the main storage room in the basement noted with worn out insulation.
4) Insulation of the Pipes in the Passover storage room in the basement observed with blackish (mold-like) discoloration.
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 03/02/09 between 9:00am and 3:30pm, the following was observed:

Water leakage was noted from a pipe and an open/broken concrete ceiling slab in the boiler room and also in the Passover storage room that is located by the staff lounge in the facility's basement.
The ceiling, walls and floor paint in the main storage room and the residents' clothing storage room was observed peeling. These rooms are located in the facility's basement. Furthermore, in the residents' clothing storage room, clean linen in numerous plastic bags was stored on shelves. The plastic bags in which the clean linen was stored were observed either broken or loosely tied and the debris from the numerous cracks in the concrete slab was observed to spill on the stored clean items.
The insulation for the water cooling system was noted to be worn and ripping off in some locations in the basement of the facility, for example the Passover storage room, the residents' clothing storage room, the clean utility storage room and the dietary storage.
The piping insulation in the Passover storage room in the basement was observed worn out, damp and with blackish/mold-like discolorations.

In an interview with the Director of maintenance on 3/2/10 at approximately 11:45 a.m. he stated that most of the leaks were as a result of condensation from the pipes that are noted with the worn out insulation and that the leak observed in the dietary storage was from the street above. He stated that he will ensure that the leaks from the concrete are patched and that he will have to speak to the administrator regarding the re-insulation of the piping because they are badly worn and flaking and that the repairs needed to address this issue would require professional inspection to check for potential asbestos contamination.

415.5(h)(2)

Based on record reviews and staff interviews, the facility did not ensure that the resident's written plan of care was followed as evidenced by the physician's order for Lab work was not done. This was evident for one (1) of thirty (30) sampled residents. (Resident #21)

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

The finding is:
Resident #21 was admitted to the facility with diagnoses which include: Diabetes Mellitus (DM), End Stage Renal Disease (ESRD), and Hypothyroidism.
The Minimum Data Set 2.0 dated 1/15/10 documented that the resident is assessed as having End Stage Renal Failure and requires Hemodialysis.
The physician's order dated 2/17/10 documented a telephone order as "T3, T4, TSH (Thyroid Stimulating Hormone), Hemoglobin A1C, Prealbumin, Lipids profile in Hemodialysis."
The nurse's note dated 2/17/10 documented, "...lab order to be done in dialysis."
The nursing note dated 2/19/10 documented, "Resident returned from Dialysis no note in book." The nurse spoke with a technician, who requested the physician's order for the labs to be faxed to the dialysis center. There is no documented evidence in the nurse's notes that the requested labs ordered were faxed to the dialysis center.
The communication book for dialysis documented that resident went to dialysis on 2/18/10, 2/20/10, 2/23/10, 2/25/10, 2/27/10, 3/2/10, 3/4/10, and 3/6/10. There was no documented evidence that the Lab blood works ordered were done on the days that the resident went to dialysis.
The Interdisciplinary care plan for Dialysis dated 1/15/10 documented a goal of "Resident will have blood levels at acceptable levels..." with an intervention to "...monitor lab values as ordered..."
The facility's policy and procedure for "Care for the Resident receiving Hemodialysis" documented that the "physician....will order lab tests and frequency for each test....The registered nurse...will implement physician's orders...send communication book to dialysis center with resident including request for blood tests and any other pertinent information in communication book."
On 3/5/10 at 10:15 A.M., the Registered Nurse (RN)/Charge Nurse was interviewed and stated that she was the nurse who noted that the lab blood works were not done on 2/18/10 upon the resident's return from the dialysis center. She further stated that she was the person who called the dialysis center, spoke with the technician, and was instructed to fax the physician's order for the lab works, which she did. Upon request the nurse could not provide evidence or a confirmation sheet showing that the physician's order was faxed to the dialysis center.
On 3/5/10 at 1:45 P.M., the Associate Nurse Manager at the dialysis center was interviewed and stated that the dialysis center could not produce any faxed copy or written notification that labs were ordered by the resident's physician.

415.11(c)(3)(ii)

REPEAT DEFICIENCY
Based on observation, it was determined that the facility did not ensure that the sectional sprinkler control valves are electrically supervised (fully supervised) so that at least a local alarm will sound when the valve is closed, as per NFPA72 and LSC 19.3.5. Reference is made to four sectional sprinkler control valves located in the kitchen section and one sectional sprinkler control valve located in the basement storage room.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The findings include:
On March 2nd and 3rd , 2010 between 9:30am and 2:30pm, it was observed that the facility is protected with the automatic extinguishing system. The main sprinkler control valve of the facility is provided with an electrical supervisory system. The sectional sprinkler control valves, (4) located in the kitchen section and (1) located in the storage room in the facility basement, lack electrical supervision that will ensure that an alarm will sound at a designated location in the facility when the valve is closed.

On March 2nd , 2010 at approximately 11:30am, the facility's Director of Maintenance stated that although issue regarding the electrical supervision of a sectional sprinkler control valve was noted in the previous survey, these sprinkler valves now identified were not pointed out. He added that valves now identified will be electrically supervised.

711.2 (a)(1)

Based on observation and interview the facility did not ensure that doors to hazardous areas were maintained self-closing or automatic closing. This was evidenced by laundry room doors in the basement being held open with unapproved devices that will not allow the doors to self close and latch.

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

Finding is:

On 3/02/10 during the life safety tour between 9:00am and 3:30pm, it was observed that the doors to the laundry room located in the basement was equipped with self-closing devices. It was also observed that the doors were held open with devices that will not allow the doors to self close and eventually latch. The doors were noted to be held open with (1) large standing fan, (2) a flat head screw driver. In addition the ventilation system was not working.
In an interview with the Director of Maintenance at approximately 11:50 a.m., he stated that the door would be properly fixed. In an interview at the same time with the laundry services personnel she stated that the door is usually held open because it gets too hot inside the room that it is unbearable.

711.2(a)(1)

2000 NFPA 101 Chapter 19-3.2.4 Medical Gas. Medical gas storage and administration areas shall be protected in accordance with NFPA 99, Standard for Health Care Facilities.

Based on observation and interview it was determined that the facility did not ensure that oxygen cylinders are stored in accordance with the requirements of NFPA 99. This was evidenced by eleven full oxygen 'e' cylinders that were stored within 1- 3 feet from combustible materials in the oxygen storage room located in the facility basement.
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 March 2, 2010 at approximately 12:20pm, it was observed that in the oxygen storage room located in the facility basement, eleven full oxygen'e' cylinders were stored approximately 1- 3 feet from combustibles. The combustibles noted include numerous plastic bags containing residents' clothes, cartons and stretcher. Oxygen storage must be separated from the storage of combustibles, in accordance with NFPA99.

In an interview at approximately 12:25pm on the same day, the Director of Maintenance stated that the facility would decide on a plan to implement to address the issue. He added that they may just relocate the oxygen tanks.

1999 NFPA 99 Chapter 8-3.1.11.2(c)2
711.2 (a)(1)

PHYSICAL PLANT VIOLATION - STATE ONLY

I. NYCRR 713 - 1.18(d)(2)(ii):
The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in table 8.

Based on observation and interview, it was determined that the facility did not ensure that the laundry/ dryer areas were supplied with at least two air changes of outdoor air per hour to the laundry area.

The findings include:

On 03/02/10, it was observed that the facility has a mechanical air supply ventilation system for the laundry room and dryer areas. The air handling system, however, was noted to be non-operational during the time of survey. There was no mechanical pull noted when tested. When interviewed, the director of maintenance said that he was unaware of the non-functionality of the exhaust system. In another interview with the director of Housekeeping on 3/03/10 at approximately 3:20 p.m. he stated that he noted that the exhaust system hasn't been working since Thursday (2/25/10) and he contacted the contractors for laundry services to have their maintenance personnel fix the ventilation.