Hillside Manor Rehab & Extended Care Center

Based on observation, and staff interview, it was determined that the facility did not ensure that the two toilet rooms located on the first floor, adjacent to the lobby area, which are accessible to the residents area equipped with the nurses' call system.

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

The findings include:
On March 9, 2011, at 10:00 M to 2:00 PM, it was observed that the facility has provided two toilet facilities, labelled as visitors' toilet, on the first floor and adjacent to the lobby area. These toilet facilities are unlocked and also accessible to residents. During the environmental tour, a male resident was observed exiting from one of these toilet facilities. There is no provision for a nurses' calling system in these toilet facilities. On March 9, 2011, at approximately 12:30 PM, the facility's director of maintenance stated that either these toilet facilities will be kept locked with keys available at the front desk for the visitors or nurses' calling system for the residents' use will be installed in these toilets.

713-2.22 (g)(2)

NYCRR 713- 2.22 (g)
(g) Nurse's calling system shall comply with the following:
(1) A call button shall be provided at each resident's bedside which calls to the nurse's station. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the resident's d oor, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at the corridor intersections. In rooms containing two or more calling stations, indicting lights shall be provided at each station. Nurses' calling systems that provide two-way voice communication shall be equipped with an indicting light at each calling station with lights, and remain lighted as long as the voice circuit is operating.

This requirement is not met as evidenced by:
Based on observation and testing of the nurses' call system provided in the residents' use areas, it was determined that the facility did not ensure that the call system is designed and maintained to register a visual signal in the clean workroom, in the soiled workroom and in the nourishment station on the 2nd, 3rd and 5th floors.

The findings include:
On March 9, 2011,at 10:00 AM to 2:00 PM, it was observed that the the facility has designed the nurse's call system to register a visible signal in the clean workroom (medication room), in the soiled workroom and in the nourishment stations (kitchenette) of the nursing units. During the environmental tour of the building, the call system was tested by placing a call from the residents' bedside and/or the residents' toilet room of the nursing unit. The calling system did not register a visual signal in the clean workroom (medication rooms), on the 2nd, 3rd and 5th floor; in the soiled workroom, on the 3rd floor and 5th floor; and in the nourishment station (kitchenette), on the 2nd , 3rd and the 5th floors. On March 9, 2011 at approximately 12:00 PM, the facility's director of maintenance stated that burnt out bulbs for the visual signals in the medication room,in the soiled workroom and in the kitchenette are being replaced and will be maintained to function, as designed..

Based on observation, it was determined that the facility did not ensure that the corridor doors to resident use areas ( physical therapy areas, and administration office) are free of impediments to closing and that the doors to the electrical panel rooms are free of transfer grilles (louvers).

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On March 9, 2011, at 10:00 AM to 2:00 PM, the following was observed:
(1) The corridor doors to the physical therapy area in the basement (LL2), and the corridor door to the administration area on the first floor were held open with rubber wedges. The rubber wedges would not allow the doors to close freely during fire or other emergency, as per 19.3.6.3.3.

(2) Two doors to the electrical panel rooms in the basement are equipped with transfer grilles (louvers), measuring 24 inches by 18 inches. Transfer grilles, with or without the fusible link - operated dampers, are not permitted in the corridor doors to resident use areas, as per 19.3.6.4.

On March 9, 2011,at approximately 11:00 AM, the facility's director of maintenance stated that the doors will be kept free of any unapproved hold open device and the transfer grilles on the electrical panel room doors will be sealed.

711.2 (a)(1)

Based on observation and testing of the electrical supervisory system, it was determined that the facility did not ensure that electrical supervisory system installed for the sprinkler control valves is designed and maintained so that at least a local alarm will sound when the valve(s) are closed, as per NFPA72 and LSC 19.3.5.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On March 9, 2011, at 10:00 AM to 2:00 PM, it was observed that the facility installed electrical supervisory system for the sprinkler control valves located in the sprinkler room in the basement. During a simulated testing (closing the sprinkler valve), the supervisory system did not sound an alarm in the lobby, as designed. On March 9, 2011, at approximately 11:15 AM, the facility's director of maintenance stated that the recent changes in the fire alarm panels have resulted in the failure of the supervisory system activation in the lobby area. The director further added that the fire alarm company is being contacted to restore the functioning of the electrical supervisory system for the sprinkler control valves, as designed.

711.2 (a)(1)

Section 5-2, NFPA10, Standard for Portable Fire Extinguishers, states that at intervals not exceeding those specified in Table 5-2, fire extinguishers shall be hydrostatically retested. The hydrostatic retest shall be conducted within the calender year of the specified test interval. In no case shall an extinguisher be recharged if it is beyond its specified retest date.

This standard is not met as evidenced by:
Based on observation, it was determined that the facility did not ensure that stored - pressure water type portable fire extinguishers installed on the 3rd and the 5th floors, were hydrostatically retested at 5 years intervals, as per Table 5-2, NFPA10.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On March 9, 2011 at 10:00 AM to 2:00 PM, it was observed that the facility installed stored-pressure water type portable fire extinguishers in the facility. The extinguishers lack the valid 5 year hydrostatic test record/label (examples are: adjacent to stair "A", on the 3rd floor, and on the 5th floor). The test labels affixed to the extinguishers revealed that extinguishers were last tested in August/September of 2005. All stored -pressure water type extinguishers are to be retested hydrostatically every 5 years and test record are to be maintained on a suitable metallic label affixed to the extinguishers' shell, as per 5-6.4, NFPA10. On March 9, 2011, at approximately 12:15PM, the facility's director of maintenance stated that all fire extinguishers with expired test dates will be replaced with new extinguishers.

711.2 (a)(1)

Based on observation, it was determined that the facility did not ensure that the the exit stair "A" enclosure, at the LL1 level is free from the passage of overhead drain pipe, as per 7.1.3.2.1 and 7.1.3.2.3.

This resulted in no actual harm with potential for greater than minimal harm that is not immediate je o pardy.

The findings include:
On March 9, 2011, at 10:00 AM to 2:00 PM, it was observed that exit stair "A" enclosure, at the LL1 level, is penetrated by an overhead drainage/sewage pipe of approximately 4 inch diameter. The drainage pipe lacks an enclosure of at least 1 - hour fire resistance rating. Any accidental water leakage from the drain pipe in the exit stairway would interfere with the safe usage of the stairway by the occupants during fire or other emergency. On March 9, 2011, at approximately 11:30 AM, the facility's director of maintenance stated that the drainage pipe penetrating the exit stair enclosure will be enclosed with at least 1 hour fire resistance rating construction.

711.2 (a)(1)