Table of Contents
Bezalel Rehabilitation and Nursing Center
Deficiency Details, Certification Survey, June 23, 2010
PFI: 3156
Regional Office: MARO--New York City Area
F323 483.25(h): FACILITY IS FREE OF ACCIDENT HAZARDS
Scope: Widespread
Severity: Potential for no more than Minimal Harm
Corrected Date: July 22, 2010
The facility must ensure that the resident environment remains as free of accident hazards as is possible; and each resident receives adequate supervision and assistance devices to prevent accidents.
Citation date: June 23, 2010
Based on observation and staff interview, windows in resident rooms and resident-use areas on four of four floors were of the double-hung variety that can be unlatched at the top of the window and tilted down into the room. This configuration would leave an unrestricted window opening and would not prevent a possible fall.
This resulted in no actual harm with potential for minimal harm that is not immediate jeopardy.
The findings are:
On 6/21/10 between 8:15am- 1:30pm during the recertification survey, resident rooms and resident-use areas on four of four floors were provided with windows noted to be of the double-hung variety that can be unlatched at the top of the window and tilted down into the room. The windows were provided with a locking mechanism that was not engaged at the time of the observations. This feature was tested by and confirmed with the Director of Maintenance. The windows were also not provided with security screens to prevent accidental falls. This situation would present a possible accident hazard as it would leave an unrestricted window opening.
In an interview on 6/21/10 at approximately 9:20am, the facility consultant stated that the windows were recently cleaned and the locks were not re-engaged afterwards. He further stated that he will re-engage the window locks immediately.
415.12(h)(1)
K53 NFPA 101, 483.70(a)(7): AUTOMATIC SMOKE DETECTION SYSTEM
Scope: Pattern
Severity: Potential for more than Minimal Harm
Corrected Date: July 22, 2010
In an existing nursing home, not fully sprinklered, the resident sleeping rooms and public areas (dining rooms, activity rooms, resident meeting rooms, etc) are to be equipped with single station battery-operated smoke detectors. There will be a testing, maintenance and battery replacement program to ensure proper operation. 42 CFR 483.70(a)(7)
Citation date: June 23, 2010
Based on observation and staff interview it was determined that the facility did not ensure that smoke detectors, at the minimum of single station battery-powered, were installed in all required locations for an existing nursing home that is not provided with a complete automatic sprinkler system. This was evidenced by the lack of smoke detectors in the residents' public areas on 4 of 4 residents' 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 inspections on 6/21/10 between 8:20am and 2:00pm it was observed that the building was not provided with a complete automatic sprinkler system in that the following areas were not provided with sprinkler coverage (not all inclusive): walk-in boxes, the boiler room, and main electrical room.
In addition, the required smoke detectors (at the minimum of single station battery-powered) were not provided in the following residents' public areas:
- The dayrooms/dining rooms located on the 2nd , 3rd , and 4th floors.
- The Main Dining Room located on the 1st floor.
- The television room located on the 1st floor.
- The arts and craft room located on the 1st floor.
At the time of the observations the areas were all accessible to the residents and there were two residents observed unaccompanied/unsupervised by employees in the arts and craft room. In an interview on the same day at approximately 9:30am the maintenance supervisor stated that the smoke detectors were never provided in the identified area as he can recall and that they would be provided.
711.2(a) (1)
K66 NFPA 101: SMOKING REGULATIONS
Scope: Isolated
Severity: Potential for more than Minimal Harm
Corrected Date: July 22, 2010
Smoking regulations are adopted and include no less than the following provisions: (1) Smoking is prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area is posted with signs that read NO SMOKING or with the international symbol for no smoking. (2) Smoking by patients classified as not responsible is prohibited, except when under direct supervision. (3) Ashtrays of noncombustible material and safe design are provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available to all areas where smoking is permitted. 19.7.4
Citation date: June 23, 2010
Based on observation and staff interview the facility did not ensure that ashtrays of a safe design (with center rests) and metal containers with self-closing cover lids were provided in the residents' smoking area located in the patio.
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 6/21/10 at approximately 8:20am, it was observed that the residents' smoking area located in the patio was not provided with ashtrays of a safe design with center rests. In addition, the area was not provided with readily available metal containers with self closing cover lids into which the ashtrays could be emptied into. At the time of the observation, seven smoking outposts were provided and residents were observed smoking in the area.
Smoking outposts are used for disposing of cigarette butts and ashes and are not substitutes for ashtrays.
In an interview at this time, the maintenance supervisor stated that the ashtrays were removed because they became rusty. He further stated that safe design ashtrays and metal containers with self closing cover lids would be provided in the smoking area.
711.2(a)(1)
K17 NFPA 101: CORRIDOR WALLS
Scope: Pattern
Severity: Potential for no more than Minimal Harm
Corrected Date: July 22, 2010
Corridors are separated from use areas by walls constructed with at least ¾ hour fire resistance rating. In sprinklered buildings, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls properly extend above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to the corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2.1, 19.3.6.5
Citation date: June 23, 2010
The following requirements of The Life Safety Code ha ve 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.
Include your request for renewal of this waiver or plan of correction in the space provided on this form.
42 CFR 483.70(a):
K 17, S/S=B
The walls which separate the patient rooms from the corridors extend only to the hung ceiling, and not to the slab above, as is required for the maintenance of the separation of the corridor.
LSC 19.3.6.1 ; 19.3.6.2.1, 711.2 (a)(1)