Bezalel Rehabilitation and Nursing Center

Based on observations and staff interview during the recertification survey, the facility did not provide sections of the resident accessible corridors and use areas with firmly secured handrails on 4 of 4 resident floors.

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

The findings are:

During environmental inspections on 8/24/11 between 8:30am and 11:30am it was noted that approximately 2 feet sections of corridors were not provided in the handrails in the following areas:

- the medical records and clean utility rooms on the 4th , 3rd and 2nd floors
none - between the smoke door and resident room 416, and between the dayroom/dining room and resident room 415 on the 4th floor
none - between the smoke door and resident room 316 on the 3rd floor
none
In addition, the areas adjacent to the elevator shafts/cabs on the 1st floor elevator lobby were not provided with handrails.

Residents were observed and unescorted in these areas during the survey.

In an interview on the same day at approximately 10:00am, a maintenance employee stated that the handrails were never installed in the identified areas on the resident floors. He also stated that the 1st floor lobby was recently renovated and that the contractor may have forgotten to install the handrails. He further stated that the issue would be discussed with the Administrator and facility fire safety consultant in order to be addressed.

415.29

Physical Plant Violations- State Only

713-1.3 Nursing units.

Each nursing unit shall include the following service areas and shall meet the following minimum requirements:

(a) A nurses' station.
ne (b) A nurses' call system that can register a call from each resident's bedside, toilet and bathing facilities to the nurses' station. The call system shall also register a visual signal at each resident's doorway, the clean room, soiled workroom and nourishment station on the nursing unit.

These requirements are not met as evidenced by:

Based on observation, testing and staff interview during the recertification survey, it was determined that the facility did not maintain the resident call system as required in 713-1.19(g)(1) to activate visible signals in the soiled utility rooms, pantry rooms and in the corridor for resident rooms on 2 of 3 resident sleeping floors.

This resulted in no actual harm with potential for minimal harm.

The findings are:

During environmental inspections on 08/24/11 between 8:30am and 11:30am, it was noted that the facility did not maintain the resident call system as required in that the visible signals at the nurses panels located inside the soiled utility and pantry rooms on the 4th and 3rd floors did not lit when tested. In addition the visible corridor lights at the resident room doors did not light up when tested for resident rooms 401 (4th floor) and 314 (3rd floor).

In an interview on the same day at approximately 10:00am a maintenance employee stated that he is unaware of the nonfunctioning call bell lights and that there might be a problem with the circuit for the call bell lights in the identified areas. He further stated that he would immediately contact the outside servicing company to fix the call bell lights.

Based on observation and staff interview during the recertification survey, the facility did not ensure that the laundry chute door was positively latching on 1 of 3 resident sleeping floors and did not ensure that the chute discharge room is completely enclosed.

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 08/24/11 between 8:30am and 11:30am, it was noted that the linen chute door on the 4th floor did not positively latch into the door frame. The latching mechanism on the chute door did no function when tested.

In addition, the chute discharge room was not completely enclosed. The chute discharge room door (leads to the laundry areas) was not provided with a positive latching device and was not self closing. An approximate 8 inches gap was noted between the door and door frame when the door was released from the open position.

In an interview on the same day at approximately 11:00am a maintenance employee stated that the issues with the doors would be discussed with the Administrator and the fire safety consultant in order to be addressed.

NYCRR 711.2(a)
10 NYCRR 415.29

Based on observations and staff interview during the recertification survey, the facility did not ensure that 1 of 2 exit stairway within the means of egress is protected and properly enclosed.

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 08/24/11 at approximately 10:45am the emergency exit stairwell (Stairwell B) was noted with a door that was propped open with a vacuum cleaner. The propped door opens into a vestibule that was noted with the storage of a large plastic bin of mop heads, and buffing pads. The other vestibule that leads to the emergency exit door was noted with the storage of pieces of sheet rock braced against the wall and four cases of " pink " cleaning solution.

In an interview at this time the maintenance employee stated that the vacuum cleaner and storage items were not supposed to be kept in this location. He immediately removed the vacuum cleaner from in front of the door and stated that the other items would be removed. He further stated that the housekeeping and maintenance employees would have to be in serviced to not use the stairwell for storage.

NYCRR 711.2(a)
10 NYCRR 415.29

7.10.1.2* Exits.
Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit access.

7.10.2* Directional Signs.
A sign complying with 7.10.3 with a directional indicator showing the direction of travel shall be placed in every location where the direction of travel to reach the nearest exit is not apparent.

Based on observation and staff interview during the recertification survey the facility did not ensure that means of egress were provided with readily visible exit signs on 3 of 3 resident sleeping floors.

This resulted in no actual harm with the potential for minimal harm.

The findings are:

During life safety inspections on 08/24/11 between 8:30am and 11:30am, it was noted that portions of the egress corridors were not provided with readily visible exit signs. Examples include the areas in the corridors facing the East and West directions on the 2nd, 3rd and 4th resident sleeping floors.

In an interview on the same day at approximately 9:00am, a maintenance employee stated that the exit signs were never installed in the identified locations and that the issue would be brought to the attention of the Administrator and fire safety consultant in order to be addressed.

NYCRR 711.2(a)
10 NYCRR 415.29

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)