Pine Haven Home

Based on observation and staff interview the facility did not ensure that the Infection Control practices were designed to provide a safe, sanitary and comfortable environment to prevent the spread of infection and disease was followed on two of three units observed during the standard recertification survey. Specifically, clean linens were stored in areas designated as a soiled area, treatment supplies that were to be used during a clean dressing change procedure were placed on an uncleaned surface and residents personal items such as urinals and bedpans were stored unlabeled hanging on a grip bar in a bathroom shared by other residents. This resulted in no harm with the potential for more than minimal harm that is not immediate jeopardy. This is evidenced by the following:

Finding # 1
North Wing

During an observation on 11/2/11 at 9:30 am the laundry aide was observed placing clean linen bags in the soiled utility room. The clean linen bags were stored in the soiled utility room under the sink counter in a plastic laundry bin.

During an interview on 11/2/11 at 9:45, the Certified Nursing Assistant (CNA) stated that the bags are kept there in case the staff needed extra bags.

During an interview on 11/8/11 at 1:10 pm, the Infection Control Nurse, stated that the clean linen bags should not be stored in the soiled utility room. She stated that only soiled items should be in that room and the staff should never take anything soiled to a clean area.

Finding # 2
Basement

During an observation on 11/3/11 at 9:30 am of the basement area the janitors supply room was observed. Supplies of paper towels, facial tissue, toilet tissue, disposable incontinent briefs and of bags of extra clean linens were observed stored in this room. In this same room were 3 soiled floor cleaning machines, two of which were in contact with the plastic bags of clean linen.

On 11/3/11 at 10:40 am, the janitor's cart room was inspected. Janitor's carts (soiled) were being stored within this room, as were clean items such as rolls of toilet tissue and paper towels.

During an interview on 11/3/11 at 9:30 am, the housekeeping supervisor stated that the staff had moved the cleaning machines to this room last week due to the room where the machines are usually kept had become to crowded. The housekeeping supervisor stated that the cleaning machines are not used on a daily basis and stated he would have them removed from the room immediately.

Finding # 3
West Wing

During an observation on 11/4/11 at 11:00 am the Licensed Practical Nurse (LPN) was observed performing a dressing change. The LPN did not wash her hands prior to the start of the treatment. The Treatment Administration Record, dated for 11/4/11, documented an order to apply skin prep ( a solution used to protect skin) to right ankle, allow to dry and wrap with dry gauze. The LPN entered the resident room and placed a small plastic cup containing a mixture of Balmex and A&D ointment ( barrier creams) on the residents bed and the tape, bandage scissors and gauze on the heater next to the bed. The LPN then removed the old dressing with scissors and placed the scissors back on the heater. The LPN applied the skin prep and immediately wrapped the ankle with the gauze. After the completion of the treatment the LPN returned the scissors, tape and remainder of the ointment to the treatment cart. The LPN did not clean the supplies prior to returning them to the treatment cart. Additionally, the containers of the mixed ointments located in the treatment cart were not labeled with a dated, resident name, or directions.

During an observation on 11/4/11 at 11:15 am, the bathroom located between rooms 20 and 22, which is shared by two male residents, was observed to have two unlabeled urinals hanging on the grip bar to the left of the toilet.

During an observation on 11/4/11 at 11:30 am, the bathroom located between rooms 17 and 19 was observed to have two unlabeled bedpans on the floor. One of the two bedpans was located behind the toilet. There was also a presence of dark mold like area around the base of the molding behind the toilet.

During an interview on 11/8/11 at 1:15 pm, the Infection Control Nurse (ICN) stated that bedpans and urinals should be labeled with either a room/bed number or resident name. She further stated that bedpans and urinals should not be stored in resident bathrooms. The ICN further stated that the LPN did not follow infection control practices during the treatment application and that clean articles should never be stored or kept in the same area as soiled supplies or items. She stated she will re-educate all staff on the importance of good infection control practices.

10 NYCRR 415.19(a)(1-4)

Based upon observation and interview, it was determined that the facility did not maintain walls, ceiling tiles, equipment, and roof in good repair and did not ensure the ceiling air vents and lighting panels were free of dust and dead insects. Specifically, water stained, sagging ceiling tiles, chipped and scuffed wall surfaces in common and individual resident rooms, a torn separating refrigerator gasket, and an ice machine was noted with accumulations of scaly deposits were noted on three of three units. Ceiling air vents throughout the facility hallways and common areas were coated with thick layers of dust. The ceiling light panels located through out the facility, including the elevator area, were observed to have evidence of dead insects and other unknown
debris. Additionally, the membrane type roof contained numerous holes. This is a repeat deficiency from the past 2 surveys. This results in the potential for more than minimal harm that is not immediate jeopardy and is evidenced (but not limited to) the following examples:

Findings:

During tour observation on three of three resident units on 11/2/11 between 9:00am and 10:00am, a majority of resident rooms were observed to have water stained and or sagging ceiling tiless. Some of the rooms were observed to have mold areas on the ceiling panels as well. The ceiling light panels located in resident rooms, common rooms and areas and hallways were observed dusty and had evidence of dead insects ( such as flies or moths). The ceiling air vents in the hallways located on two of three the units and in the basement were observed to have thick layers of dust.

The hallway between rooms S 2 and S 4 contained sagging, water and black mold stained ceiling tiles when observed on 11/2/11 at 9:30 am. Water stained ceiling tiles were additionally noted outside room S 22 and in the corridor between rooms N 14 and N102 between 9:30 and 9:55 am on same day. The roof was inspected on 11/3/11 at 1:50 pm. The roof membrane other than the area covering the core area of the building, was observed with numerous holes especially at the perimeter. Many of the holes were greater than one foot. The Senior Maintenance Staff was interviewed during this inspection stated the roof was approximately two years old.

Scuffed and scraped surfaces were noted on the corridor wall between rooms S213 and S 11, at 9:35 am, and on the heater unit within the bathing area of south unit at 2:05 pm on 11/2/11.

The gasket of the refrigerator within the nourishment room of south unit, was observed to be separating and hanging off when observed on 11/2/11 at 9:46 am. The ice machine within this same room, at same time, was noted with accumulations of scaly deposits on the dispenser nozzle cover.

During an interview on 11/2/11 at 11:50 am, the housekeeping aide stated she did not believe their was a set schedule or program for cleaning of the vents. She stated that she will dust the vents whenever she notices a build-up of dust. She did not know how often the ceiling panels for the lighting were cleaned and stated she believed it was done by the maintenance staff.

Upon interview with the Senior Maintenance Staff , it was stated that the facility lacks a Director of Maintenance, or other person in charge of building maintenance that is onsite on a continual basis.

The Administrator was interviewed on 11/3/11 at 3:30 pm regarding the water stained ceiling tiles who stated that roof repairs are expected to begin within the next few weeks.

10NYCRR415.5(h)(2)

Based upon interview and review of inspection records, it was determined that the automatic sprinkler system was not being inspected in accordance with NFPA 25. NFPA 25 requires components such as the alarm devices to be tested on a quarterly basis. Specifically, the sprinkler system had not been inspected for the first two quarters of this current year. This results in the potential for less than minimal harm that is not immediate jeopardy, and is evidenced as follows:

Sprinkler inspections were not performed for the first two quarters of 2011. The Automatic Sprinkler Inspection Reports were reviewed on 11/3/11 at 9:30 am. The most recent sprinkler inspection report performed was dated 8/22/11, and was for the current (third) quarter of this year. The last sprinkler inspection that was performed prior to that was dated 11/22/10, and was within the fourth quarter of 2010. The Senior Maintenance Staff was interviewed to determine if any sprinkler inspections or reports were performed between 11/22/10 and 8/22/10. The Senior Maintenance Staff stated that there were no reports during that time and the sprinkler contractor had gone out of business causing the lag.

10 NYCRR 415.29(a)(2), 711.2(a)(1),
NFPA 101 (2000 ed.) 19.3.5.2, 9.7.1.1, NFPA 25 1-10, 2-1, NFPA 13 12-1

Based upon observation and interview, it was determined that one of five exit doors equipped with delayed egress locking mechanisms tested, did not release. These doors were designed to release in fifteen seconds upon applying pressure to the release device. Specifically, an exit door within a resident common space room did not release in fifteen seconds, or thereafter when tested, as posted on this exit door. This results in the potential for more than minimal harm that is not immediate jeopardy and is evidenced as follows:

The exit door within the activities room was equipped with a delayed egress lock which was designed to release in 15 seconds upon the initial application of pressure to the releasing mechanism. This door was tested for operation on 11/3/11 at 2:18 pm, and did not release. The Senior Maintenance staff was interviewed at this time who stated that they (the facility) will have to get the contractor company in to fix.

2000 LSC (NFPA 101) 19.2, 7.1.10.1, 7.5.1.1, 7.7.1
NYCRR 711.2(a)(1), 1997 LSC (NFPA 101) 13-2.7, 5-5.1.1, 5.7.1

Based upon interview and review of documentation, it was determined that the facility did not exercise the emergency generator for 30 minutes per month under load conditions. 1999 NFPA 99 \i Standard for Health Care Facilities section 3-4.4.2 and 1999 NFPA 110 \i Standard for Emergency and Standby Power Systems section 6-3.4 requires that the facility maintain operational testing records that include the date, exercising period, identification of the servicing personnel and identification of any unsatisfactory condition with the appropriate corrective action and re-testing. 1999 NFPA 110 section 6-4.2 requires generator sets to be exercised under load at least monthly for 30 minutes. This resulted in the potential for more than minimal harm that is not immediate jeopardy. This is evidenced as follows.

Log sheets for the periodic running of the facility emergency generator were reviewed on 11/3/11 at 10:15 am. Weekly generator runs were noted on these log records, however it could not be determined if any of these generator tests (runs) were conducted under full load, at least on a monthly basis. These records were reviewed in the presence of the Senior Maintenance Staff who was interviewed at this time. The Senior Maintenance Staff stated that the generator runs automatically on a weekly basis, however it is not run under full load conditions unless a power outage occurs.

1999 NFPA 99 3-4.4.1, 3-4.4.2; 1999 NFPA 110 6-3.4, 6-4.2; 1996 NFPA 99 3-4.4.1, 3-4.4.2; 1996 NFPA 110 6-4; 10 NYCRR 415.29, 711.2(a)(1)

Based upon observation, interview, and review of inspection reports, it was determined that the facility did not consistently perform monthly inspections of all the facility fire extinguishers on three of three units and all non residential areas. Section 4-3.1 of the Standard for Portable Fire Extinguishers, (NFPA 10), requires inspections be performed on a monthly basis, at a minimum. Specifically, all of the fire extinguishers were not inspected for at least two consecutive months of the current year. This results in the potential for less than minimal harm that is not immediate jeopardy and is evidenced as follows:

On 11/3/11 at 10:25 am, the inspection tags for the two fire extinguishers located in the boiler room were observed. One extinguisher had a lapse in inspections for three months, i.e. from 5/13 to 9/13, and the other extinguisher was dated only 9/13 and 10/27.

The fire extinguisher adjacent to the elevator machine room had a tag indicating monthly inspections dated 5/13, 6/22, 9/13, and 10/27. This extinguisher was lacking inspections for June and July. This observation was noted on 11/3/11 at 10:45 am.

The inspection tag of the fire extinguisher on the wall of the west basement storage room was checked on 10/3/11 at 10:30 am. The inspection dates for the tag were: 5/13, 6/22, 9/13, and 10/27. This extinguisher lacked inspections for June and July.

The centralized monthly inspection log sheet for all of the fire extinguishers was reviewed on 11/3/11 at 9:50 am. Inspection checks were noted lacking for the months of July and August of 2011. The Senior Maintenance Staff was interviewed at this time who stated that this log was for all of the fire extinguishers in the building and that the team that was out here at the time (July and August) didn't know it needed to be done.

10 NYCRR, 415.29(a)(2), 711.2(a)(1)
2000 LSC NFPA 101: 9.7.4.1, 19.3.5.6, 1998 NFPA 10: 4-3.1

LSC 1997: 13-3.5.6, 7-7.4.1
NFPA 10 1994 edition: 4-3.1,

Based upon observation and interview, it was determined that the facility did not maintain one area of exit discharge free of obstructions. Specifically, the cement pad and cement stairs from a (non-resident) basement exterior exit discharge was obstructed with weeds (i.e. small tree) growth. This results in the potential for minimal harm that is not immediate jeopardy and is evidenced as follows:

Two of two basement exit discharge pathways were inspected on 11/3/11. The exterior exit dishcarge adjacent to the MDS office was observed at 10:10am. The segment just outside the exit door consists of a cement concrete pad leading to cement stairs. Two thick weeds, (small trees) greater than four feet in height were noted growing up through the concrete, in the direct egress pathway. The Senior Maintenance staff was interviewed and was unaware of when or how often this exit is checked for obstructions such as these.