Oceanview Nursing & Rehabilitation Center, LLC

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that clinical records on each resident were maintained in accordance with accepted professional standards and practices that are complete and accurately documented. A) This is evident in 3 (Residents #2, #17 and #3, ) of 20 total sampled resident records reviewed for completeness of the plan of care and services provided. Specifically, A1) Resident #2 has an order for an antibiotic to be given twice daily for 7 days. The medical record documented that the antibiotic was administered 10 times out of the 14 times order. A2) Resident #17 has an order to stop Coumadin 4.5 milligram (mg) and change to 5 mg. The Medication Administration Record (MAR) revealed that Coumadin (an anticoagulant) 4.5 mg and 5 mg were given on the same date as documented by the initials of the licensed staff. A3) Resident #3 has an order of Liquid Fiber Flow (a fiber supplement) to be administered for 10 days. The medical record documented only 9 days of administration. B) This is evident for 4 (Residents #8, #3, #18, and #16) of the 20 sampled resident records reviewed for accurate documentation. Specifically, B1) Resident #8's clinical record contained documented evidence that the resident was administered with Oxygen (O2) via nasal cannula on the days that the resident was in the hospital. The record also contained documented evidence of an O2 saturation (a measure of how much Oxygen the blood is carrying in percentage) on the day that the resident was in the hospital. B2) Resident #3 has a Physician Monthly Order that had been altered after it was duly signed by the Physician. B3) Resident # 18 has order for Finger stick (FS- blood sugar test by finger prick) three times a week twice a day. The medical record revealed that this was done once only for the week. B4) Resident #16 has order for Enalapril (an anti-hypertensive medication) 20 mg to be held on Dialysis days: Mondays, Tuesdays and Fridays. The medical record reveal that the Physician's order was not accurately followed. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy at a pattern level.

The findings include but are not limited to:

A1) Resident #2 has diagnoses including Cellulitis.

The Physician Order dated 4/20/11 documented Biaxin (an antibiotic) 500 milligram (mg) PO two times daily for 7 days for diagnosis of Bilateral Lower Extremities Cellulitis.

An Interim Physician Note dated 4/20/11 documented "noted redness of both lower leg lower portion and positive stasis edema of both legs. Start Biaxin."

The MAR dated 4/21/11 documented Biaxin 500 mg PO two times daily for 7 days give with meals for diagnosis of Bilateral Lower Extremities Cellulitis. The MAR also documented that Biaxin was administered twice on 4/21/11 and 4/23/11 through 4/25/11. Biaxin was administered only once on 4/22/11 and 4/26/11 and none on 4/27/11. The resident received a total of 10 doses instead of the 14 doses of Biaxin as ordered.

The Licensed Practical Nurse (LPN) that was responsible for administering the resident's Biaxin and did not initialed the MAR to indicate that the antibiotic was administered on that day was not available for interview.

The Medical Director was interviewed on 6/2/11 at 8:10 AM. The Medical Director stated that Biaxin and Liquid Fiber Flow should be administered completely as ordered.

The Registered Nurse (RN) Supervisor/Charge Nurse was interviewed on 6/2/11 at 1:00 PM. . The RN stated that the licensed staff should have signed or initialed the MAR box to indicate that the medication was administered.

A2) Resident #17 has diagnoses including Left Basal Ganglia Infarct and Transient Ischemic Attack (TIA).

The Physician's order dated 4/22/11 documented to stop Coumadin 4.5 mg by mouth at bedtime and start Coumadin 5 mg at bedtime.

The MAR dated 4/22/11 documented that Coumadin 4.5 mg and 5 mg were administered as documented by initials of the licensed staff.

The LPN who was responsible for the administration of the medication was not available for interview.

The Director of Nursing services (DNS) was interviewed on 6/2/11 at 1:10 PM. The DNS stated that she expects the licensed staff to encircle the Coumadin 4.5 mg dose to indicate that this was not administered.

The medical record contained no documented evidence that only Coumadin 5 mg was administered and that Coumadin 4.5 mg was stopped.

The facility's policy revised 6/2011 titled Medication Administration documented procedures that include to "take the required vital signs ...Before completion of shift, reviews all medication records for which he/she has been responsible to determine that all medications have been given and charted as ordered ... If medications possess a pattern of refusal, it should be reported to the RN Supervisor who will assess the resident and notify the physician for appropriate action ...".

B 1) Resident #8 has diagnoses including Chronic Obstructive Pulmonary Disease (COPD) and Pneumonia.

The Physician's Order dated 4/20/11 documented O2 saturation level every shift and to notify the Physician if less than 90%. (Normal range from 95 to 100%).
The Physician's Order dated 4/20/11 documented O2 at 2-3 liters per minute (l/min) via nasal cannula for Shortness of Breath (SOB).
The Nurses' Note (N/N) dated 5/14/11 documented that Resident #8 was found on the floor at 7:35 PM. The O2 saturation documented was at 79% and that the resident had generalized weakness. The N/N further documented that the Physician was called and that the resident was transferred to the hospital at 8:35 PM.
The Nursing Process Documentation Form Admission Record dated 5/19/11 documented that Resident #8 was readmitted to the facility on 5/19/11.
A review of the Medication Administration Record (MAR) dated 5/14/11 documented an entry for the 11:00 PM- 7:00 AM shift of an O2 saturation level for Resident #8 at 97%, despite documented evidence that the resident was in the hospital on the above date.
A review of the Treatment Administration Record (TAR) dated 5/15/11 documented entries for the 11:00 PM-7:00 AM shift, 7:00 AM- 3:00 PM shift and 3:00 PM-11:00 PM shift that the resident was administered with O2 at 2-3 l/min via nasal cannula. TAR also documented on 5/16/11 for the 11:00 PM- 7:00 AM shift that the resident was administered O2, despite documented evidence that the resident was in the hospital on the above dates.
An interview with the Unit Charge Registered Nurse (RN) was conducted on 6/1/11 at 11:30 AM. The RN stated that she could not identify the nurses who signed the dates that the resident was administered O2 via nasal cannula when the resident was documented to be in the hospital during those dates.
An interview was conducted with the Director of Nursing Services (DNS) on 6/2/11 at 11:00 AM. The DNS stated that the MAR and TAR should not have been signed if the resident was out of the facility. The DNS also stated that a signature bank was initiated to identify licensed staff signatures.
B2) Resident #3 has diagnoses including Diabetes Mellitus (DM) and Chronic Renal Failure (CRF).
The Physician's Monthly Order dated 5/30/11, signed by the Physician and reviewed by three licensed staff, documented a diet order: No concentrated sweets, low fat, low cholesterol, a line was observed drawn across the word regular and was replaced with "chop", salt diet.
An interview was conducted with the Registered Dietitian (RD) on 5/31/11 at 11:00 AM. The RD stated that the resident's diet was previously "regular" diet and was changed to "chop". The "salt diet," as documented on the 5/30/11 Physician's Monthly Order, was brought to the attention of the RD as to what kind of "salt diet." The RD also stated that the resident has no salt diet.
On 5/31/11 at 11:20 AM, the RD together with the Unit RN Supervisor came back to the surveyor bringing the Physician's Monthly Order dated 5/30/11. The Order dated 5/30/11 documented some alterations on the diet order that included: No concentrated sweets, a line across low fat, low cholesterol, a line across regular and replaced with "chop" with the word "diet" added and the RN's initial, and a line across salt diet with the RN's initial and dated 5/30/11.
The Unit RN Supervisor was immediately interviewed and stated that she can alter the documented diet order (Physician's Monthly Order dated 5/30/11) since she was in the facility on 5/30/11 and had previously reviewed the order. The RN also stated that a nurse can alter the document.
An interview was conducted with the Medical Director on 6/2/11 at 8:00 AM. The Medical Director stated that once the Physician's Order is signed, it cannot be altered. The Medical Director also stated that it is a legal document and that any further changes of the Physician's Monthly Order are to be done using the Interim Physician Order, which is the purpose of the form.
An interview was conducted with the DNS on 6/2/11 at 1:10 PM. The DNS stated that the nurse should not have altered the Physician's Monthly Order after it was duly signed by the Physician. The DNS also stated that any further changes of the order should be documented with an Interim Physician Order.

415.22(a)(1-4)

Based on observation, staff interview and record review during the Recertification Survey the facility did not ensure that one of twenty sampled resident receive care in a manner and in an environment that maintains or enhances each resident's dignity and respect in full recognition of his or her individuality. Specifically, Resident #17 was observed on 5/31/11 at 12:15 PM ambulating in her room from bed to sink, pants down around her ankles, exposed, with the door open. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #17 has diagnoses which includes Falls Syncope and Cerebral Vascular Accident.

The Minimum Data Set dated 4/27/11 documented a Brief Interview for Mental Status score of 10 which indicates the resident's cognition was moderately impaired and required limited assistance with ambulation.

The resident was observed on 5/31/11 at 12:15 PM ambulating in her room from her bed to the sink, her pants were down around her ankles, exposed, with the door open. A staff member was present in the room.

A monthly Summary Activity of Daily Living Code Form dated 5/18/11 documented the resident needed supervision with ambulation.

An interview was conducted with the Certified Nursing Assistant (CNA) on 5/31/11 at 12:17 PM. The CNA stated that she was watching the resident and that she should have provided the resident with privacy.

An interview was conducted with the Director of Nursing (DNS) on 6/2/11 at 11:00 PM. The DNS stated the CNA should have assisted the resident with her clothing and provided her with privacy.

415.5(a)

Based on observation and staff interview, paved areas directly outside of emergency exits presented a possible tripping hazard in that areas were noted with cracked and uneven elevations in concrete. This was noted outside of the main entrance and the emergency exit from the service corridor. This was noted for two of seven emergency exit locations.

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

The findings are:

On 5/27/11 between 10:00am- 11:00am during the recertification survey, areas of cracked and uneven concrete were noted in the vicinity of emergency exits. Examples include but are not limited to:
1) Approximately 4 foot long cracks in the concrete in the vicinity of the main entrance.
2) An approximately 4 foot wide section that is elevated and uneven where the driveway runs perpendicular to the exit discharge in the vicinity of the service corridor.

In an interview on 5/27/11 at approximately 10:40am, the Director of Maintenance stated that he would address all the areas of concern immediately.

415.12(h)(1)

Based on record review and laboratory provider and staff interviews during the recertification survey, the facility did not ensure that laboratory services ordered by the Physician was completed. This is evident in 1 of the 20 total sample resident records reviewed. Specifically, Resident #13 has an order for Fasting Blood Sugar (FBS) every month. This was not completed for the months of April 2011 and May 2011. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #13 has diagnoses including Diabetes Mellitus.

The Physician's Monthly Order dated 4/26/11 and 5/30/11 documented FBS monthly.

The medical record contained no documented evidence of an FBS result for April 2011 and May 2011. The last documented FBS on file was dated 3/25/11.

The Registered Nurse Supervisor/Charge Nurse was interviewed on 6/1/11 at 11:00 AM and 6/2/11 at 10:00 AM. The RN stated she will be locating the FBS documentation for April 2011 and May 2011. The RN had not provided any documentation until exit time of the survey.

The Medical Director was interviewed on 6/2/11 at 8:10 AM. The Medical Director stated that laboratory tests should be completed as ordered.

The Laboratory Provider was interviewed on 6/2/11 at 8:30 AM. The Provider stated that there was no documentation that an FBS was completed for April 2011 and May 2011. The Provider also stated that there was no laboratory slip made out for the resident so that the laboratory technician could draw the blood for FBS.

The facility's policy dated 1/29/09 titled Laboratory Testing documented " ...Unit RN manager will review laboratory book daily to ensure ordered laboratory tests are scheduled and completed as ordered by the Physician.

415.20

Based on record review and staff interview during the recertification survey the facility did not ensure that a resident to resident altercation was thoroughly investigated for 2 of 5 residents in a total of 20 sampled residents reviewed. Specifically, Resident #5 and Resident #16 had a documented physical altercation with a subsequent hospitalization for both residents. There was no documented evidence that an investigation was completed for either resident.

The findings are:

1) Resident #5 has diagnoses which includes Schizophrenia and Seizure Disorder

The Minimum Data Set (MDS) dated 3/23/11 documented the resident's cognition was moderately impaired

The nursing notes dated 2/27/11 documented that the resident punched Resident #16 in the face when he was grabbed by him.

The Physician Order dated 2/27/11 documented to transfer the resident to Psychiatric (Psych) Facility Emergency Room (ER).

The Comprehensive Care Plan for Resident to Resident Altercation dated 12/1/10 and updated 2/27/11 documented in the outcome/evaluation section the resident was grabbed in the shirt by Resident #16 then he punched him in the face.

The Social Service progress note dated 2/28/11 documented that the social worker was made aware that the resident was involved in an altercation and was sent to Psych ER for evaluation.

An interview was conducted with the Director of Nursing (DNS) on 6/1/11 at 10:45 AM regarding the resident to resident incident (Resident #5 and Resident #16) . The DNS stated an Accident/Incident investigation was not available and that she expected one should have been completed.

The Facility Policy on Resident to Resident Altercation/Abuse/Dispute revised 3/4/2011 documented when a resident to resident altercation has occurred the Nursing Supervisor will investigate and obtain necessary statements from the resident, staff involved and other witnesses.

2) Resident #16 has diagnoses which includes Chronic Renal Failure and Hypertension.

The MDS dated 2/28/11 documented a Basic Interview for Mental Status BIMS score of 12 (which indicated the resident's cognition was moderately impaired).

The nurses note dated 2/27/11documented physical altercation between resident and Resident #5. The Physician was notified and ordered the resident to be sent to the hospital for Psych Evaluation.

The CCP for Resident to Resident (Aggressor) documented resident hit another resident transfer to Psych Hospital.

An interview was conducted with the DNS on 6/1/11 at 10:45 AM regarding the resident to resident between Resident #5 and Resident #16 . The DNS stated an Accident/Incident investigation was not available and that she expected one should have been completed.

The Facility's Policy on Resident to Resident Altercation/Abuse/Dispute revised 3/4/2011 documented when a resident to resident altercation has occurred the Nursing Supervisor will investigate and obtain necessary statements from the resident, staff involved and other witnesses.

415.4(b)(1)(ii)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that a resident maintains an acceptable parameters of nutritional status such as body weight unless the resident's clinical condition demonstrates that this is not possible. This is evident in 2 of 4 residents reviewed for nutrition in a sample of 20 resident records. Specifically, Residents #17 and #18 had documented significant weight increases in one month period. There was no documented evidence in the medical record the weight increases were verified by reweighing the resident as required. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #17 has diagnoses including Bipolar Disorder.

The Weekly/Monthly Weight Record documented the following weights:
3/1/11 - 164.8 pounds (lbs)
4/6/11 - 172.6 lbs

The medical record contained no documented evidence that a reweigh of the resident was done to determine that the weight increase was accurate.

2) Resident #18 has diagnoses including Uncontrolled Diabetes.

The Weekly/Monthly Weight Record documented the following weights:
5/12/11 - 188.6
5/16/11 - 198.6

The Dietitian's Note dated 5/16/11 documented "...will get reweigh...".

The medical record contained no documented evidence that a reweigh of the resident was done to determine that the weight increase was accurate.

The Registered Dietitian (RD) was interviewed on 6/1/11 at 11:00 AM. The RD stated that it is the nursing department's responsibility to weigh and reweigh the resident if needed.

The Registered Nurse (RN) Supervisor was interviewed on 6/1/11 at 11:20 AM. The RN stated that it is the responsibility of the interdisciplinary team to reweigh the resident and not just the nursing department.

The facility's undated policy titled Weight and Heights documented "...reweighs are required when there is a weight gain or loss of more than or equal to 5 pounds in one month ...".

415.12(I)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that services provided or arranged by the facility were provided by qualified persons in accordance with each resident's written plan of care. This is evident in 2 of 20 total sampled resident records reviewed. Specifically, 1) Resident #7 had documented pattern of refusal for her anti-gout medication, a nasal spray and a fiber supplement. There was no documented evidence that the Physician was notified to take appropriate action. 2) Resident #13 has an order that required to hold Atenolol (an anti-hypertensive medication) if the heart rate is below 60. The Medication Administration Record revealed that HR was not obtained prior to administering Atenolol 30 times. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #7 has diagnoses including Asthma, Chronic Obstructive Pulmonary Disease (COPD) and Osteoarthritis (OA).

The Physician's Order dated 4/21/11 documented Allopurinol (anti-gout medication) 100 milligram by mouth daily for increase uric acid.

The Physician's order dated 3/15/11 documented Saline Nasal Spray (a nasal passage moisture solution) one spray in each nostril three times daily and Liquid Fiber Flow (a fiber supplement) 30 cc by mouth at (HS).

The Medication Administration Record (MAR) reviewed for April 2011 documented the following:
a) Saline Nasal Spray one spray in each nostril three times daily- the resident refused 14 times from 4/15/11 through 5/6/11
b) Allopurinol 100 milligram by mouth daily - the resident refused 3 times from 4/22/11 through 5/6/11
c) Liquid Fiber Flow 30 cc by mouth at HS - the resident refused 7 times from 4/17/11 through 4/27/11.

The medical record contained no documented evidence that the licensed staff, who documented the resident's refusal by encircling their initials in the MAR, notified the Physician for appropriate action when the resident's plan of care was not followed.

The Licensed Practical Nurse who had documented the resident's refusal by encircling their initials in the MAR, was interviewed on 6/2/11 at 11:00 AM. The LPN stated that she should have notified the Physician.

The Medical Director was interviewed on 6/2/11 at 8:10 AM. The Medical Director stated that she expects the licensed staff to inform the Physician if the there was a pattern of refusal of the medication intake by the resident for any further appropriate action.

2) Resident #13 has diagnoses including Hypertension and Cerebrovascular Accident (CVA).

The Physician's Order dated 3/24/11 documented Atenolol 25 milligram (mg) one table by mouth daily and hold for systolic blood pressure below 100 or heart rate below 60.

The MAR dated 3/26/11 through 4/24/11 documented Atenolol 25 mg one table by mouth daily and hold for systolic blood pressure below 100 or heart rate below 60. The MAR reviewed did not have documented evidence that the resident heart rate was obtained prior to Atenolol administration 30 times.

The Licensed Practical Nurse who had administered the Atenolol with no documentation of heart rate was interviewed on 6/2/11 at 11:10 AM. The LPN stated that she should have documented the heart rate..

The Medical Director was interviewed on 6/2/11 at 8:10 AM. The Medical Director stated that she expects the licensed staff to follow the Physician's order of obtaining the heart rate prior to administration of Atenolol.

The facility's policy revised 6/2011 titled Medication Administration documented procedures that include to "take the required vital signs ...Before completion of shift, reviews all medication records for which he/she has been responsible to determine that all medications have been given and charted as ordered ... If medications possess a pattern of refusal, it should be reported to the RN Supervisor who will assess the resident and notify the physician for appropriate action ...".

415.12

Based on observations and staff interviews conducted during the standard survey, it was determined that the facility did not ensure personal privacy and/or confidentiality of records for 20 of 20 residents in the standard recertification survey of 2010. Specifically, the names, room numbers and survey numbers of residents 1 through 20 in the Plan Of Correction Survey Result was posted in a public area of the facility. This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy.

Findings include:

During the initial tour of the facility on 5/27/11 at 9:30 AM, the 2010 survey results were posted on the wall in the main lobby which is assessable to visitors, staff and residents. The 2010 survey results included a list of residents names, room numbers and survey identification numbers of residents reviewed during the 2010 survey.

During an interview with the Director of Nursing Services (DNS) and the Administrator on 5/27/11 at 10:00 AM, they were unaware that the list of residents had been posted with the survey results. The DNS stated that the results of the previous survey were posted prior to her coming to the facility.

415.3(d)(1)

Based on record review and staff interviews during the recertification survey, the facility did not ensure that residents grievances were resolved in a timely manner. This was evident in 1 out of sample residents reviewed for grievances. Specifically, Resident #22's roommate took $5.00 from her nightstand drawer. The medical record contained no documented evidence that the facility offered Resident #22 a locked drawer to prevent future occurrence. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #22 has diagnoses including Early Dementia.

The Social Service Note dated 5/19/11 documented that the resident's roommate (Resident #17) went to Resident #22's drawer and took $5.00.

The Comprehensive Care Plan developed for Abuse Prevention dated 4/12/11 did not have documented evidence that the resident was offered a locked drawer to prevent future occurrence of personal properties taken.

The Director of Social Work (SW) reviewed the resident's medical record on 6/2/11 at 10:30 AM. The SW stated that she could not locate any documentation that the facility offered the resident a locked drawer.

The SW also reviewed files in her office but could not provide any documentation pertaining to the facility providing a method of securing the resident's valuables.

415.3(c)(1)(ii)

The following waiver is on file with this office. Repeat waiver is granted based on previous justification by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waiver has been granted has not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction.

Single patient room E5 provides 90 square feet, not 100 square feet as required.
The multipatient rooms provide only 72 square feet per bed: E1, E2, E3, E4, E5, E6, E7, E8, E9, E10, E13, E20, E21, E22, W1, W2, W4, W5.

NYCRR 711.5(c)7

Based on observation and staff interview during the recertification survey it was determined that the facility did not ensure that doors protecting corridor openings are maintained to resist the passage of smoke/fire on two of two units and, kept free of impediment to closing on one of two units.

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

The findings are:

During life safety inspections on 05/27/11 between 8:30am and 11:00am the following was noted:

1) Corridor doors were observed with gaps at the door frames and the door meeting edges. In addition the positive latching devices on the doors were not engaged or did not function when tested. Examples include the following:

a. The service corridor that is located adjacent to the East wing unit:

- paper goods supply closet
- porter's closet
- dishwashing room

b. The corridor door to resident rooms E-2 and E-12 on the East unit.

2) The corridor door to resident room E-11 on the East unit was observed to be impeded from closing by a protruding bed that was observed within the door's swing space.

In an interview on the same day at approximately 10:45am, the Director of Maintenance stated that all door problems would be immediately fixed. He immediately contacted a maintenance employee to fix the identified doors.

NYCRR 711.2(a)
10 NYCRR 415.29

NFPA 101, 2000 Edition
19.2.2.2.4
Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side.
Exception No. 1: Door-locking arrangements without delayed egress shall be permitted in health care occupancies, or portions of health care occupancies, where the clinical needs of the patients require specialized security measures for their safety, provided that staff can readily unlock such doors at all times. (See 19.1.1.1.5 and 19.2.2.2.5.)
Exception No. 2*: Delayed-egress locks complying with 7.2.1.6.1 shall be permitted, provided that not more than one such device is located in any egress path.
Exception No. 3: Access-controlled egress doors complying with 7.2.1.6.2 shall be permitted.

19.1.1.1.5
It shall be recognized that, in buildings housing certain types of patients or having detention rooms or a security section, it might be necessary to lock doors and bar windows to confine and protect building inhabitants. In such instances, the authority having jurisdiction shall make appropriate modifications to those sections of this Code that would otherwise require means of egress to be kept unlocked.

NFPA 101, 2000 Edition
Chapter 7.2.1.6.1 -7.2.1.6 Special Locking Arrangements.
7.2.1.6.1 Delayed-Egress Locks.
Approved, listed, delayed-egress locks shall be permitted to be installed on doors serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6, or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 12 through 42, provided that the following criteria are met.
(a) The doors shall unlock upon actuation of an approved, supervised automatic sprinkler system in accordance with Section 9.7 or upon the actuation of any heat detector or activation of not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6.
(b) The doors shall unlock upon loss of power controlling the lock or locking mechanism.
(c) An irreversible process shall release the lock within 15 seconds upon application of a force to the release device required in 7.2.1.5.4 that shall not be required to exceed 15 lbf (67 N) nor be required to be continuously applied for more than 3 seconds. The initiation of the release process shall activate an audible signal in the vicinity of the door. Once the door lock has been released by the application of force to the releasing device, relocking shall be by manual means only.
Exception: Where approved by the authority having jurisdiction, a delay not exceeding 30 seconds shall be permitted.

NFPA 101, 2000 Edition
7.1.10 Means of Egress Reliability. 7.1.10.1 Requires that means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency.

This STANDARD is not met as evidenced by:

Based on the observations and staff interviews during the recertification survey the following was noted:

1.The unapproved use on non conforming magnetic locking devices were observed on emergency exit doors on two of two units.
2. Power sliding doors from the main dining room were provided with a thumb turn locking mechanism.
3.There is no paved walkway to the public way from the East and West courtyard exits in the vicinity of the nursing stations.

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

The findings are;

During life safety inspections on 05/27/11 between 8:30am and 11:00am the follosing were noted:

1.It was noted that the main entrance and service corridor doors are both equipped with magnetic door locking devices that can be opened by entering a code in the adjacent keypads. Testing of the locking devices for delayed egress features revealed that they are not equipped to release within 15 seconds when a continuous force is applied to both doors for more than three seconds. Further testing at approximately 10:00am revealed that only the main entrance door magnetic locking device is connected to the building's fire alarm system and released when the fire alarm system was activated. Both doors have exit signs pointing to them.

In an interview on the same day at approximately 9:00am the Director of Maintenance stated that both magnetic locking devices are not equipped with delayed egress features and that he is unaware if the facility has approval from the local Authority Having Jurisdiction (AHJ) for their use. He further stated that he would discuss the issue with the Administrator and provide the approval for the locks if there is any.

The facility did not provide the approval documentation issued by the local AHJ for the usage of the magnetic locking devices on the doors.

2. A set of power sliding doors to the main dining room was provided with a thumb turn locking mechanism. In the event of a loss of power with the thumb turn locking mechanism engaged, the doors would not breakaway.

3. The East and West emergency exits in the vicinity of the nursing stations discharge to a paved back courtyard. Egress from the back courtyard to the public way would be over a grassy and uneven area as there is no alternative paved walkway. The grassy area presents an impediment to safe egress over an uneven surface.

In an interview on 5/27/11 at approximately 10:40am, the Director of Maintenance stated that he would address all the areas of concern immediately.

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 that waiver(s) to be continued.

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

A soiled linen shed is located at the West Wing exit. If it became involved with fire, it could obstruct the exit. 7.1,19.2.1.

1998 NFPA 96- Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations
7.2.2.1
Automatic fire-extinguishing systems shall be installed in accordance with the terms of their listing, the manufacturer"s instructions, and the following standards where applicable.
(a) NFPA 12, Standard on Carbon Dioxide Extinguishing Systems
(b) NFPA 13, Standard for the Installation of Sprinkler Systems
(c) NFPA 17, Standard for Dry Chemical Extinguishing Systems
(d) NFPA 17A, Standard for Wet Chemical Extinguishing Systems

1998 NFPA 17A- Standard for Wet Chemical Extinguishing Systems
5.2 Owner's Inspection.
5.2.1
Inspection shall be conducted on a monthly basis in accordance with the manufacturer's listed installation and maintenance manual or the owner's manual. As a minimum, this " quick check " or inspection shall include verification of the following:
(a) The extinguishing system is in its proper location.
(b) The manual actuators are unobstructed.
(c) The tamper indicators and seals are intact.
(d) The maintenance tag or certificate is in place.
(e) No obvious physical damage or condition exists that might prevent operation.
(f) The pressure gauge(s), if provided, is in operable range.
(g) The nozzle blowoff caps are intact and undamaged.
(h) The hood, duct, and protected cooking appliances have not been replaced, modified, or relocated.

5.3.1.1*
At least semiannually, maintenance shall be conducted in accordance with the manufacturer's listed installation and maintenance manual. As a minimum, such maintenance shall include the following:
(a) A check to see that the hazard has not changed
(b) An examination of all detectors, the expellant gas container(s), the agent container(s), releasing devices, piping, hose assemblies, nozzles, signals, all auxiliary equipment, and the liquid level of all nonpressurized wet chemical containers
(c) * Verification that the agent distribution piping is not obstructed
(d) Where semiannual maintenance of any wet chemical containers or system components reveals conditions such as, but not limited to, corrosion or pitting in excess of the manufacturer's limits; structural damage or fire damage; or repairs by soldering, welding, or brazing; the affected part(s) shall be replaced or hydrostatically tested in accordance with the recommendations of the manufacturer or the listing agency. The hydrostatic testing of wet chemical containers shall follow the applicable procedures outlined in Section 5-5.
(e) All wet chemical systems shall be tested, which shall include the operation of the detection system signals and releasing devices, including manual stations and other associated equipment. A discharge of the wet chemical normally is not part of this test.
(f) Where the maintenance of the system(s) reveals defective parts that could cause an impairment or failure of proper operation of the system(s), the affected parts shall be replaced or repaired in accordance with the manufacturers' recommendations.
(g) The maintenance report, with recommendations, if any, shall be filed with the owner or with the designated party responsible for the system.
(h) * Each wet chemical system shall have a tag or label securely attached, indicating the month and year the maintenance is performed and identifying the person performing the service. Only the current tag or label shall remain in place.

Based on observation, staff interview and record review, 1) the last documented ANSUL inspection, indicated by tags on the pull station and canisters, was July 2010; and 2) there were no documented monthly ANSUL inspections provided at the time of the survey. This was noted in the kitchen.

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

The findings are:

On 5/27/11 at approximately 8:30am during the recertification survey, the following was noted in the kitchen:

1) The last documented ANSUL inspection as indicated by tags on the pull station and canisters, was July 2010.

2) There were no documented monthly ANSUL inspections provided at the time of the survey.

In an interview on 5/27/11 at approximately 12:05pm, the Director of Environmental Services stated that she would call the company to inspect the ANSUL system immediately and will document the monthly visual checks.

2000 NFPA 101- 19.3.2.6, 9.2.3
1998 NFPA 96- 7.2.2.1
1998 NFPA 17A- 5.2.1, 5.3.1.1
711.2(a)(1)

2000 NFPA 101 LSC Chapter 7.9.3 Periodic Testing of Emergency Lighting Equipment.
A functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

Based on observation, staff interview and record review, there was no documentation provided regarding the annual 1hour test on battery-powered emergency lighting.

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

The findings are:

On 5/27/11 between 8:30am- 12:00pm during the recertification survey, battery-powered emergency lights were noted throughout the facility. During facility record review at approximately 12:30pm, there was no documentation of the annual 1hour test of the battery-powered emergency lights provided during the survey.

In an interview on 5/27/11 at approximately 1:45pm, the Director of Environmental Services stated that she will revise the documentation to reflect the annual testing.

711.2(a)(1), 2000 NFPA 101: 7.9.2.1, 7.9.2.2, 7.9.3

2000 NFPA 101- Chapter 19.3.3.2 Interior Wall and Ceiling Finish.
Interior wall and ceiling finish materials complying with 10.2.3 shall be permitted as follows:
(1) Existing materials - Class A or Class B
Exception: In rooms protected by an approved, supervised automatic sprinkler system, existing Class C interior finish shall be permitted to be continued to be used on walls and ceilings within rooms separated from the exit access corridors in accordance with 19.3.6.

Based on observations and record review during the recertification survey, the facility was unable to provide documentation that the interior finish for rooms and spaces had a flame spread rating of at least Class A or Class B. Reference is made to a folding partition in the main dining room.

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

The findings are:

On 5/27/11 at approximately 10:05am during the recertification survey, a folding partition was noted in the main dining room. The folding partition did not bear any indication (e.g., label, tag) of its flame spread rating. Additionally, the facility is a partially sprinklered building requiring the flame spread rating to be at least Class A or Class B.

In an interview on 5/27/11 at approximately 10:05am, the Director of Maintenance stated that he would look into finding the documentation for the flame spread rating.

711.2(a)(1), 2000 NFPA 101: 19.3.3.1, 19.3.3.2.

NFPA 99 Section 8-3.1.11.2
Storage for nonflammable gases less than 3000 ft3 (85 m3).
(a) Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limited-combustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry.
(b) Oxidizing gases, such as oxygen and nitrous oxide, shall not be stored with any flammable gas, liquid, or vapor.
(c) Oxidizing gases such as oxygen and nitrous oxide shall be separated from combustibles or incompatible materials by either:
1. A minimum distance of 20 ft (6.1 m), or
2. A minimum distance of 5 ft (1.5 m) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems, or
3. An enclosed cabinet of noncombustible construction having a minimum fire protection rating of one-half hour for cylinder storage. An approved flammable liquid storage cabinet shall be permitted to be used for cylinder storage.
(d) Liquefied gas container storage shall comply with 4-3.1.1.2(b) 4.
(e) Cylinder and container storage locations shall meet 4-3.1.1.2(a) 11e with respect to temperature limitations.
(f) Electrical fixtures in storage locations shall meet 4-3.1.1.2(a) 11d.
(g) Cylinder protection from mechanical shock shall meet 4-3.5.2.1(b) 13.

Based on observation and staff interview during the recertification survey, the facility did not ensure that the storage oxygen cylinders in excess of 300 cubic feet within the facility were stored at a minimum of 20 feet from combustible items and that the lighting fixture was provided explosion proof on 1 of 2 units.

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

The findings are:

During life safety inspections on 05/27/11at approximately 10:15am it was noted that the oxygen storage room on the East Wing contained the storage of 15 small oxygen tanks (e-tanks) within 2-3ft. of combustible items (ie wooden shelves, cardboard boxes of nasal canula, and plastic regulators). In addition, the light fixture within the oxygen storage room was not of the explosion proof type.

Observations further revealed that the building is partially sprinklered and the oxygen storage room was not provided with sprinkler coverage.

In an interview at this time the Director of Maintenance stated that the storage in the room would be maintained to minimum of 13 e-tanks so as to be incompliance.

NYCRR 711.2(a)
10 NYCRR 415.29

NFPA 101, 2000 Edition
Life Safety Code section 19.3.7.3 requires smoke barriers to be constructed in accordance with section 8.3 and shall have a fire resistance rating of not less than \'bd-hour.

Based on observation and staff interview during the recertification survey the facility did not ensure that smoke barriers are maintained to provide at least a half hour fire resistance rating on one of two nursing units. Reference is made to use of unapproved fire stopping material (polyurethane foam) for penetrations of the smoke barriers above a set of smoke barrier doors.

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

The findings are:

During inspections of the smoke barriers on 05/27/11 between 10:45am and 11:15am it was noted that two areas of penetrations (telephone wire and a bundle of communication wires) above the smoke barrier doors of the West Wing was sealed with unapproved fire stopping material (polyurethane foam).
none
At approximately 11:20am the Director of Maintenance provided a container of the material used to seal the identified penetrations which indicated that it is " expanding polyurethane foam " and did not indicate a fire resistance rating of at least 30minutes. In an interview on the same day at approximately 11:30am the Director of Maintenance stated that the identified material used in the smoke barrier would be removed and that the approved fire stopping material would be used.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observation and interview the facility did not maintain the Fire Alarm System in a reliable operating condition in accordance with NFPA 72 as evidenced by a non-functional and improperly installed smoke detector on 1 of 2 units.

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

The findings are:

During life safety inspections on 05/27/11 at approximately 10:50am it was noted that a hardwired smoke detector was not properly installed (i.e. resting on the ceiling tile within the interstitial space above the ceiling) and maintained over the smoke barrier door of the East Unit.

In an interview at this time the Director of Maintenance stated that the smoke detector is nonfunctional due to getting wet from a leak from a water line nearby. He stated that it has been identified by the fire alarm testing company for approximately one month and that the fire alarm company is waiting for a replacement smoke detector. He further stated that he would immediately contact the fire alarm company to expedite the replacement of the identified smoke detector.

NYCRR 711.2(a)
10 NYCRR 415.29

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 that waiver(s) to be continued.

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

A copy machine is located in the alcove adjacent to the administration office. This alcove opens into the lobby. 19.3.2.1.