Resort Nursing Home

Deficiency Details, Certification Survey, September 10, 2012

PFI: 1694
Regional Office: MARO--New York City Area

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K145 NFPA 101: EMERGENCY ELECTRICAL SYSTEM

Scope: Pattern

Severity: Potential for more than Minimal Harm

Corrected Date: September 20, 2012

The Type I EES is divided into the critical branch, life safety branch and the emergency system in accordance with NFPA 99. 3.4.2.2.2.

Citation date: September 10, 2012

Based on observation, staff interview and record review, the facility did not provide a Type 1 Essential Electrical System (EES) in that wiring from the critical branch (C) and life safety branch (LS) was noted in the same emergency power panel boards.

This was noted on seven of eight floors in a building equipped with a certified ventilator unit.

This is a repeat deficiency.

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

The findings are:

During the life safety code inspections on 09/04/12 between 8:30am and 2:00pm it was noted that wiring from both the critical branch and life safety branch was in the same emergency power panel boards. It was noted that the facility has a ventilator unit on the 2nd floor requiring the facility to have a Type 1 EES. Circuits serving both the " #1 Nurse Call System " (C), " #3 Exits " (LS) and " #5 Emergency Light " (LS) were noted in emergency power panel boards in the medication rooms on floors 2-8.

In an interview on the same day at approximately 12:30pm, the Administrator stated that he sent in a time limited waiver request in order to address the issue and that he hasn't received a reply.

A record review of NYSDOH records indicated that the facility was cited for the issue during the 08/25/11 recertification survey and requested a time limited waiver. The records further indicated that the justification for the time limited waiver request lacked adequate information and could not be processed.

NYCRR 711.2(a)
10 NYCRR 415.29

K144 NFPA 101: GENERATORS INSPECTED/TESTED

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: September 20, 2012

Generators are inspected weekly and exercised under load for 30 minutes per month in accordance with NFPA 99. 3.4.4.1.

Citation date: September 10, 2012

Based on record review and staff interview during the recertification survey, it could not be determined that the load testing for 1 of 1 emergency generator set was completed within the last twelve months. There was no documented evidence of the load testing provided by the facility.

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

The findings are:

During a record review of the facility's emergency generator logs for the last twelve months on 09/04/12 at approximately 12:00pm, it was noted that the last documented load testing for the emergency generator load test was 07/17/11. There were no additional documented load test records provided by the facility after this date.

In an interview at approximately 12:15pm, a maintenance employee sated that the facility switched their documentation form for the generator set load tests and that the load tests were not documented by error. He further stated that the load tests were completed on time, and that the testing form would be corrected to indicate the generator load tests.

NYCRR 711.2(a)
10 NYCRR 415.29

K29 NFPA 101: HAZARDOUS AREAS - SEPARATION

Scope: Isolated

Severity: Potential for more than Minimal Harm

Corrected Date: September 20, 2012

One hour fire rated construction (with hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Citation date: September 10, 2012

Based on observation and staff interview during the recertification survey, the facility did not ensure that hazardous areas were safeguarded by self-closing and positive latching doors. This was evidenced by doors to hazardous areas failing to self-close, and positively latch when tested on 1of 7 resident use floors.

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 code inspections on 09/04/12 between 8:30am and 2:00pm, the following corridor doors to hazardous areas on the 'L' level were not self closing and did not positively latch when tested:

- Paint storage room
- Housekeeping storage room
- Medication storage room
- File storage room

In on the same day at approximately 11:30pm, a maintenance employee stated that the issue with the doors would be brought to the attention of the Director of Maintenance and Administrator in order to be addressed.

NYCRR 711.2(a)
10 NYCRR 415.29