Holliswood Care Center Inc

Based on observation and interview it was determined that the facility did not ensure that a clean, comfortable and homelike environment is provided to the residents. Reference is made to:ne 1) Dusty/dirty windows and window sillsne 2) Scratch marks on doorsne 3) Dirty and chipped base boards
4) Ripped/peeling wall papers
5) Peeling paints on door frames
6) Rusty radiators
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.nene The findings are:nene During the environmental tour conducted on 06/23/11 and 06/24/11 between 9:00am and 3:00pm, the following was noted: ne 1) The windows and window sills in resident units were observed dirty and/or dusty; for example rooms 101, 103, 105, 106C, 107, 109, 214 and 4th floor dining room. Examples not all inclusive.
2) Scratch marks were observed on doors to resident rooms on various floors; for example rooms 105 A &B, 204, 221, 237, 239, 429, 437, 439, 4th floor smoke barrier doors, suite 106, suite 426 and rooms 426 A, B, C, D, the bathroom by room 109 and porters' closet by room 205. Examples not all inclusive.
3) The base board on the stretch of the 2nd and 4th floor corridors and the 2nd and 3rd floors day/dining rooms was observed dirty. Chipped base board was observed on the 2nd floor corridor between the porters' closet and shower room by room 231. Examples not all inclusive.
4) Ripped/peeling wall papers were noted on the corridor by rooms 220, 225, between rooms 214 and 216, and also in 431 alcove. Stains were noted along the wall paper ends in the 3rd and 4th floor dining rooms. Examples not all inclusive.
5) The paint in the door frames of the following rooms were observed peeling - 210, 211, 212, 213, 3rd floor shower room and the linen closet both by room 319 and the porters' closet by room 405. The door frame of room 431A bathroom was rusty. Examples not all inclusive.
6) Radiators were observed rusty; for example in the 3rd floor dining room and room 420A. Examples not all inclusive.

Other issues noted include dirty hand washing sink in the beauty parlor on the 2nd floor, dirty grouting in the 2nd floor main bathroom, broken/cracked wall by the door to the 2nd floor day room and the 4th floor soiled utility room, rusty ceiling tracks and rusty bathroom rod was observed in the 4th floor main bathroom. The 5th floor clean utility room cabinet was broken, the bottom cabinet had broken knobs with two missing drawers.

In an interview with the Director of Maintenance on 06/24/11 at approximately 11:50am, he stated that the facility has not done any renovations in a long time but now, has plans for gradual renovation of all areas of the facility.
ne 415.5(h)(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 are equipped with latching/locking device which could be released with only one releasing operation from the egress side and that the door lock releasing devices are the familiar type door releasing devices which could be operated even in darkness. Reference is made to doors that are equipped with the thumb twist type locks.
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 06/23/11 and 06/24/11 between 9:00am and 3:00pm, doors were observed equipped with a dead bolt type locking device in addition to the regular door handle type latching/locking device. The dead bolt type locking device is equipped with the thumb twist type lock releasing device. These door fastening devices, when engaged, would require more than one operation to open the door from the egress side (the twisting of the thumb-twist lock releasing device and operating the door handle to release the regular door latching device). Also, the thumb-twist type lock releasing device would be difficult to locate and operate during darkness. Examples of such doors include but not limited to doors to the medical storage room, telephone equipment room, housekeeping storage, linen storage, maintenance shop and storage, central supply and the kitchen storage room all in the facility's basement. Other doors also noted with the thumb twist type lock from the egress side are the doors to the administrators office, the social service office, office supply storage by the administrators office and the pantry rooms (for example on the 3rd and 4th floors).

In an interview with the Director of Maintenance on 6/24/11 at approximately 12:10pm, he stated that if the thumb twist type locks are unacceptable, they will remove them. He added that they were installed for security reasons.

711.2(a)

Based on observation, interview and record review the facility did not ensure that:
1) Fire protection/safety device (fire blanket) was provided in the red metal box (fire blanket station) located/placed in the smoking room on the 5th floor.
2) All staff were appropriately trained in fire safety and emergency procedures in accordance with 19.7.2. Reference is made to the staff members in the recreational area not being included in the facilities fire safety drill.
This resulted in no acutal harm with the potential for more minimal harm that is not immediate jeopardy.

The findings are:

On 06/23/11 and 06/24/11 an Annual Life Safety inspection was conducted.The facility provides a smoking room for residents on the fifth floor. Further observations revealed that a fire blanket station was provided within the smoking room; however,when opened the fire blanket was found to be missing. This has the potential to impact the fire safety measures for the residents in an event of fire or smoke.

In an interview with the Housekeeping Director on 06/23/11 at 11:00 am, he stated that some residents would pull the blankets from the box and this may be the reason for the missing fire blanket.

Also, designated times were provided for the residents who smoke and staff are assigned to supervise them. In an interview with a recreational aide he states that he provides direct supervision for the residents and that he took part in a fire drill " two months ago". However, review of the facility fire drills for the previous one year did not indicate that any of the recreational aide members took part in the fire drills as evidenced by lack of signatures.

NFPA 101 19.7.2
NYCRR 415.29

Based on observation, it was determined that the facility did not ensure that the exit corridors/passageways in the basement and resident units are maintained free of all obstructions and impediments to full instant use in case of fire or other emergency. Reference is made to the storage of items such as carts and wheelchairs on the corridors.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The findings are:

During the LSC inspection conducted on 06/23/11 and 06/24/11 between 9:00am and 3:00pm storage of numerous items which includes 12 large linen carts, Hoyer lifts, wheel chairs, a buffer, and several boxes of diapers were observed stored in the basement corridor. The storage of linen carts (clean/soiled linen), medication carts, wheel chairs, Geri chairs and Hoyer lifts were observed on the resident unit corridors (particularly floors 2 through 6). On 06/23/11 on the 2nd floor, two medication carts were stored on the corridor by room 217 opposite the nursing station such that the space provided on the corridor (width) was less that the required 4ft. That section of the corridor at the time of inspection was congested.

In an interview regarding storage in the basement corridor on 06/24/11 at approximately 11:55am, the Director of Maintenance stated that in his opinion he did not consider the items left on the basement corridor as storage, that they do not have a place to keep them and that the Housekeeping Director may be able to give me more information on the issue.
At approximately 12:00pm, in an interview, the Housekeeping Director stated that they do not have much space and that now that it has been brought to his attention, they will have to come up with a different idea as to where to store the carts.

711.2(a)

2000 NFPA 101 LSC Chapter 19.3.5 Extinguishment Requirements.
19.3.5.1
Where required by 19.1.6, health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7.

9.7.1.1- Each automatic sprinkler system required by another section of this Code shall be in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems.

1999 NFPA 13, 5-13.8* Exterior Roofs or Canopies.
5-13.8.1
Sprinklers shall be installed under exterior roofs or canopies exceeding 4-ft (1.2 m) in width.

Based on observation and interview it was determined that the facility did not ensure that the two canopies provided in the patio area/ " outside smoking area " which exceeds 4-ft (1.2 m) in width were equipped with an automatic extinguishing system or were constructed with non-combustible material.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

During the Life Safety Code inspection conducted on 06/23/11 at approximately 10:00am, it was observed that two canopies were provided in the patio/ " outside smoking area " at the side of the building. One of the canopies measured over 6ft while the other measured over 18ft in width and they were made of fabric.
The facility is a fully sprinklered building but no sprinklers were provided in the canopies neither was there any documentation or proof presented by facility staffs to show that the canopies were constructed with non-combustible material.

In an interview with the Director of Maintenance at the same time, he stated that the canopies are made of fabric and that he will check to see if there is any document available that shows they are made/treated to be non-combustible. At the exit conference on 06/24/11 at approximately 3:05pm, the administrator stated that there was no document available at the time to show that the canopies were fire rated or treated to be fire resistant.

711.2(a)(1)

Based on observation and staff interview, it was determined that the facility did not ensure that there is no impediment to the closing of corridor doors as required by2000 NFPA 101. Reference is made to corridor doors that were propped open using unapproved door hold open devices like chocks and twines.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

During the LSC inspection conducted on 06/23/11 between 9:00am and 3:00pm, the following corridor doors in the basement were observed propped open using unapproved door hold open devices - the Medical records room propped open with a plastic chock, dental office propped open with a chair and then a wood chock, linen storage and housekeeping storage room doors propped open with strings and the housekeeping storage (the wheel chair storage area) room door was propped open with a twine (not all inclusive).

In an interview with the Director of Maintenance on 06/24/11 at approximately 12:05pm, he stated that he had already ordered acceptable door hold open devices for the doors noted.

711.2 (a) (1)

NYCRR 711.2 (a)(26) - NFPA99 - 1996- Standard for Health Care Facilities.

Section 3 - 4.1.1.15, NFPA99, states that a remote annunciator, storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station (see NFPA 70, National Electrical Code, Section 700-12).
The annunciator shall indicate alarm conditions of the emergency or auxiliary power source as follows:

(a) Individual visual signals shall indicate the following:
1. When the emergency or auxiliary power source is operating to supply power to load.
2. When the battery charger is malfunctioning.

(b) Individual visual signals plus a common audible signal to warn of an engine-generator alarm condition shall indicate the following:
1. Low lubricating oil pressure.
2. Low water temperature (below those required in 3-4.1.1.9)
3. Excessive water temperature.
4. Low fuel - when the main fuel storage tank contains less than a 3-hour operating supply.
5. Overbank (failed to start)
6. Overspeed

Where a regular work station will be unattended periodically, an audible and visual derangement signal, appropriately labeled, shall be established at a continuously monitored location. This derangement signal shall activate when any of the conditions in 3-4.1.1.15(a) and (b) occur, but need not display these conditions individually. (110:3-5.5.2)

Based on observation and interview, it was determined that the facility did not ensure that a remote annunciator, storage battery powered, is provided at a continuously monitored location which will activate an audible and visual alarm signal whenever any of the engine-generator alarm condition stated under 3-4.1.1.15 occurs at the emergency power generating equipment.
This resulted in no actual harm with potential for greater than minimal harm that is not immediate jeopardy.

The finding is:

During the annual environmental survey conducted on 6/23/11 between 9:00am and 3:00pm, it was observed that the facility is equipped with an emergency generator located outside the building by the front entrance. At approximately 10:10am, it was observed that a remote annunciator, storage battery powered, was not provided for the generator.

In an interview with the Director of Maintenance that same day at approximately 10:15am, he stated that the generator was not equipped with a remote annunciator panel and that it was an old generator.