Livingston Hills Nursing & Rehabilitation Center, LLC

Based on observation, medical record review and staff interview during the standard recertification survey, the facility did not ensure that residents with pressure sores received the necessary treatment and services to promote healing and prevent new sores from developing for two (#s 10 and 108) of five residents reviewed. Specifically, the facility did not ensure that effective interventions were properly implemented to promote healing of pressure sores for one resident or to prevent sores from developing for a resident, who was assessed at high risk for developing pressure sores. This resulted in actual harm for Resident #108. This was evidenced by:

1. Resident #108
The facility did not ensure adequate off-loading of the resident's heels to promote healing of pressure areas.

The resident was admitted to the facility on 8/26/10 with diagnoses of dementia, cerebrovascular accident, and hypertension. The Minimum Data Set (MDS) dated 9/1/10 assessed the resident as having short term and long term memory loss and moderately impaired decision making skills. It also assessed the resident as having two stage II pressure ulcers. It noted that the resident had received ulcer care and preventative or protective foot care in the last seven days, but had no history of resolved pressure ulcers in the last 90 days. Additionally, the resident was assessed as requiring extensive assistance of two staff with bed mobility, as requiring total assistance of two staff for transfers and as being non-ambulatory.

The Initial Nursing History and Assessment dated 8/26/10 and completed by a registered nurse (RN), noted that the resident had a right heel pressure ulcer. A nurse's note written by a RN, dated 8/26/10 documented that the resident had a deep tissue injury to the right heel.

The Pressure Sore Flow Sheets tracked and measured weekly the right heel starting on 8/26/10 and the left heel area on 8/31/10. These flow sheets staged both areas each week as deep tissue injuries and documented that the treatment to these areas included skin prep and off-loading of the heels. The right heel was tracked as measuring 4 centimeters (cm) in length by 3.5 cm in width on 8/26/10 with a yellow/purple bruised wound bed appearance; as measuring the same on 8/31/10 with the same wound bed appearance; and as measuring 4.5 cm in length by 5 cm in width on 9/7/10 with a black wound bed appearance. The left heel was tracked as measuring 2.5 cm in length by 3 cm in width on 8/31/10 with a purple/yellow/red bruised wound bed appearance; and then as measuring 2.5 cm in length by 3.5 cm in width on 9/7/10 with a purple/yellow wound bed appearance.

A Braden Scale for Predicting Pressure Sore Risk form was first completed on 8/26/10 and scored the resident to have 12 points. The form defined a score of 10 to 12 to be high risk for pressure sores.

A Pressure Ulcer Risk Factor form was completed on 8/26/10 and noted that the resident had risk factors of hypertension, diabetes, chronic bowel incontinence, immobility, cognitive impairment, and refusal of care or treatment.

A Comprehensive Care Plan (CCP) titled, At Risk for Skin Breakdown, was initiated on 8/26/10, related to previous skin breakdown, immobility, bowel and bladder incontinence, refusal of turning and positioning, and poor nutritional status was dated 8/26/10. An intervention of off-loading (the heels) with pillows was documented on this care plan.

A CCP titled, Impaired Skin Integrity was initiated on 8/26/10. It documented that the resident had a right heel pressure sore noted on 8/26/10 and a left heel pressure sore noted on 8/31/10. The care plan identified off-loading of the resident's heels with pillows.

The Resident Activity of Daily Living Care Card (a form referenced by the caregivers to provide care) was dated 8/26/10. It documented under skin care and protection, that the resident's heels were to be off-loaded with pillows.

A second Braden Scale for Predicting Pressure Sore Risk form was completed on 9/8/10 and scored 13 points. The form defined a score of 13 to 14, to be at moderate risk for pressure sores.

A Pressure Ulcer Risk Factor form was completed on 9/8/10 and noted that the resident had risk factors of hypertension, diabetes, chronic bowel incontinence, immobility, cognitive impairment, refusal of care or treatment, and poor skin turgor.

The resident was observed on 9/13/10 at 7:40 am lying in bed, turned slightly on his right side facing the wall. He was noted to have sheets covering his feet. Two pillows were noted resting on top of the sheet that was covering the resident's feet. The resident's heels were not off-loaded.

An observation of the resident on 9/13/10 at 8:30 am was made of the resident lying in bed. At this time, the resident was lying on his back with the head of his bed raised. His feet continued to be under a sheet, not elevated or raised. He was observed to continue with two pillows resting on top of the sheet, that was covering the resident's feet.

An observation of the resident in bed on 9/13/10 at 10:15 am was made in the resident's room, while accompanied by a Certified Nursing Assistant (CNA #1). Upon the surveyor's request to see the resident's feet, CNA #1 lifted the two pillows off of the sheet, covering the resident's feet. Visual observation was made of both the resident's heels having direct contact with the bed surface and not being off-loaded.

During an interview with the CNA #1 on 9/12/10 at 10:15 am, she stated that the resident should have had pillows under his calves, so his heels were not touching the bed. She stated that she had not placed the pillows under the resident's calves in the morning, after care was completed because she thought the nurse was going to come in to do the resident's treatment on his heels. CNA #1 stated that the resident should not have gone without the pillows under his calves and without his heels off-loaded.

An observation of the resident in bed was made on 9/14/10 at 9:55 am, while being accompanied by CNA #2. CNA #2 went to the resident's room, with the surveyor and lifted the sheet off of the resident's feet. At the time of this observation, the resident's left heel was noted on top of and in contact with, one flat pillow and the resident's right heel was also noted on top of and in contact, with another separate flat pillow. CNA #2 stated that they used pillows at the facility to off-load resident heels, but that to do this appropriately, they really need to roll the pillows up and then put the pillows under the resident's calves, so that the heels hang off the pillow and do not touch the bed. She stated that she wished that the facility had some other way to off-load resident heels, because with just using the one pillow under each calf, it was difficult to properly off-load resident heels.

During an observation of the resident's pressure ulcers on 9/14/10 at 10:00 am, the right and left heels were open to air, with no dressing applied. The right heel was measured at approximately 4.0 cm in length by 5 cm in width, with a reddish brown wound bed appearance on the inner aspect of the heel. The left heel measurement was approximately 2.5 cm in length by 3.5 cm in width, with a dried gray/yellow/brown blister appearance, which was unstageable.

During an interview with the Registered Nurse Unit Manager (RNUM) on 9/15/10 at 10:35 am, she stated that at this facility, pillows are the sole intervention used for off-loading of resident heels. She defined off-loading of resident heels to mean, that resident's heels should be floating in the air and should be off of the surface of the bed and pillow at all times. She stated that sometimes the staff should use two or three pillows under the residents' calves to properly float and off-load the resident's heels. She stated that it can be difficult using the facility pillows to off-load resident heels and that sometimes the staff need to fold the pillows in half, in order to properly elevate the heels up off of the surface of the bed. She stated that due to this resident's current heel pressure ulcers, the resident's heels should have been off-loaded at all times.

2. Resident #10
The facility did not ensure that off-loading of the heels occurred as ordered by the physician for this resident who was a high risk for the development of pressure sores.

The resident was admitted on 11/4/08 with diagnoses of diabetes mellitus, bilateral hemiplegia, and cerebral vascular accident. The MDS dated 6/30/10 assessed the resident as having short term and long term memory problems and as having moderately impaired decision making skills. The MDS also assessed the resident to have one stage II pressure ulcer (on the back of the neck). Additionally, it assessed the resident as requiring total dependence with two person assistance for bed mobility and transfer status and non-ambulatory.

Physician orders dated 8/5/10 documented an order to off-load bilateral heels on pillows.

The Braden Scale dated 9/2/10 revealed the resident was scored at a 9 which equated to the resident being high risk for pressure ulcers on the score key. The pressure ulcer risk factors included immobility and severe peripheral vascular disease.

The Resident Activities of Daily Living care card, dated as having been last revised on 7/14/09 (the most current care card in the resident's room) did not have off-loading to heels documented.

The CCP for Activities of Daily Living dated 7/15/10, did not document to off-load heels.

The Potential for Skin Integrity/Impairment CCP dated 4/24/10 updated 7/14/10, did not document off-loading to heels.

There was no documented evidence that a weekly pressure flow sheet was started for this resident's heels.

During an observation on 9/13/10 at 12:05 pm, the resident was observed in bed with a pillow under his calves. His feet and heels were noted to be laying on and directly touching the mattress.

During an observation on 9/14/10 at 9:10 am the resident was noted in bed, with a pillow under his his calves and his heels were again noted to be laying on and directly touching the mattress.

During an observation on 9/14/10 at 12:20 pm, the resident was out of bed in a gerichair with his feet elevated. There was a blanket covering him, but his feet were visible out from the bottom of the blanket and his heels were noted to be directly touching the chair.

In an observation on 9/15/10 at 8:45 am, the resident was in bed with a pillow under his calves and his heels were noted to be laying on and directly touching the mattress.

During an interview on 9/14/10 at 12:20 pm, with CNA #1, she stated that the resident was supposed to have his heels off-loaded when in bed. She stated that a pillow was to be put under the resident's legs. She stated that the pillows were flat and needed to be rolled to get the resident's heels properly up off the mattress. CNA #1 then stated this information would be noted on the resident's care card. Upon surveyor review of the care card with CNA #1, it was noted that off-loading of the heels was not documented.

During an interview with the RNUM on 9/14/10 at 12:25 pm, she was questioned where the order for off-loading of the resident's heels would be documented for staff and in response, she stated it should be on the resident's ADL care card. The RNUM stated she updated the care card, at the time of this interview to reflect that off-loading of heels should be done with the resident. She further stated that the staff knew they should be off-loading this resident's heels, despite this information not having been on the care card.

In an observation on 9/15/10 at 8:45 am, the resident was in bed with a pillow under his calves and his heels were noted to be laying on and directly touching the mattress.

During observation of care with CNA #s 1 and 2 on 9/15/10 at 9:35 am, the resident was cared for and positioned in bed. Neither CNA did any care or positioning of the resident's feet/heels during the observation. The CNAs completed their care and the surveyor then asked to see the resident's feet. The resident's feet/heels were observed to be laying on and in direct contact with the mattress. At the time of this observation, a LPN was present in the room, who then off-loaded the resident's heels, and proceeded to inform the CNAs that this resident must have his heels off the mattress.

During an interview with CNA #2 on 9/15/10 at 10:04 am, he stated the pillow was always under the resident's legs to keep the heels off the bed. When further questioned regarding the heels having been observed directly in contact with the mattress even with a pillow under the resident's legs, CNA #2 responded by stating that the pillows were flat and that they do not place more than one pillow under the resident's legs.

10NYCRR 415.12(c)(2)

Based on observation, medical record review, family interview and staff interview, the facility did not ensure that it maintained clinical records on each resident in accordance with accepted professional standards and practices that are complete, accurately documented, readily accessible and systematically organized for one (# 121) of thirteen residents reviewed, during the standard recertification survey. Specifically, the facility did not ensure complete and accurate records concerning one resident's potential significant weight loss, variability in weights, the potential causes for this variability and interventions done to improve the nutritional intake for the resident. Additionally, physician progress notes did not document the resident's weight loss. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:

Resident # 121
The resident was admitted to the facility on 3/1/10 with diagnoses of dementia, schizoaffective disorder and chronic obstructive pulmonary disease. The Minimum Data Set (MDS) dated 6/26/10 assessed that the resident as having short-term and long-term memory problems and as having decision making impairments. It also identified as having had a weight loss and having been on a planned weight change program.

The Weight Graphic Sheet found in the resident's medical record documented the resident was noted to weigh 133 pounds on 5/18/10 , to weigh 121 pounds on 6/9/10 , to weigh 122 pounds on 6/10/10 , to weigh 116 pounds on 7/6/10 , and to weigh 123 pounds on 7/6/10. According to the weights on this Weight Graphic Sheet, it appeared there was a significant weight loss of approximately 8 to 10 percent from May 2010 to June 2010.

A Nutritional Risk Assessment dated 6/29/10 documented weights of: 134 pounds in March 2010, 134 pounds in April 2010, 133 pounds in May 2010, and 120 pounds in June 2010. According to the weights in this Nutritional Risk Assessment it also appeared from March 2010 to June 2010 that the resident had a significant weight loss of approximately 8 to 10 percent as well..

When the facility was questioned regarding this significant weight loss an additional weight record was produced. A Master Monthly Weight Form and a Master Weekly Weight Form documented the resident to weigh 128 pounds on 3/15/10, 128 pounds on 3/22/10, 133.5 pounds with a reweight on 129 pounds on 3/29/10, 127.75 pounds on 4/5/10, 133.5 pounds on an undated day in April 2010 , 126 pounds on an undated day May 2010, 126 pounds on 5/3/10, 128 pounds on 5/4/10, and 118.8 pounds two times on 6/23/10. These weights reflected variability from the weights documented on the Weight Graphic Sheet and in the Nutritional Risk Assessment. This led to questions about the the accuracy of the resident's weights. There continued to be a potential 5 percent weight loss noted from May 2010 to June 2010 based on all the weights available.

There was no documented evidence in the resident's medical record referencing the resident's potential weight loss prior to 6/23/10 and nothing about the resident's variability in weights.

A physician progress note dated 6/11/10 documented that the physician was asked to see the resident due to behavior changes. There was no mention of weight loss having occurred with this resident. Actions were taken to address the resident's behavior, but there was no documented evidence referencing the resident's weight loss.

During an interview with the Director of Nursing (DON) on 9/15/10 at 12:20 pm, she was asked about the resident's weight loss. She stated they were doing things to address it. She stated that the nurses were giving the resident Ensure (a nutritional supplement), and that the resident would drink this well. She stated this was not documented anywhere. She stated that there had been problems when weighing the resident because she would squirm when she was weighed, because she had an oxygen tank on the wheelchair and the tank could have had different amounts of oxygen in it when she was being weighed, and because she also thought that there had problems with the accuracy of the scale. She stated there was no documented evidence for any of this rationale written in the resident's medical record. She looked at the physician progress notes and stated there was no documented evidence addressing the resident's weight loss until the day the resident was sent to the hospital on 6/23/10 for having pneumonia.

10 NYCRR 415.22 (a) (1-4)

Based on observation, medical record review and staff interviews the facility did not provide or obtain from an outside resource, in accordance with .75(h) of this part, routine and emergency dental services to meet the needs of each resident; and did not promptly refer residents with lost or damaged dentures to a dentist for one (#107) of one residents reviewed,during the recertification survey. Specifically, the resident did not have dentures replaced in a timely manner. This caused no actual harm but had the potential for more than minimal harm. This was evidenced by the following:

Resident #107
The resident was admitted on 10/12/07 with diagnoses of dementia with behavioral disturbance, diabetes mellitis and hypertension. The Minimum Data Set (MDS) dated 6/24/10 assessed the resident as having short term memory problems and long term memory problems and moderately impaired decision making skills. The MDS dated 2/11/10 assessed the resident as having dentures and/or a removable bridge.

The Comprehensive Care Plan (CCP) titled, Oral/Dental Health-upper and lower dentures, most recently dated 6/22/09, documented that on 7/9/10 that the assessment was ongoing and on 9/9/10, that the resident's dentures were being made for replacement.

The CCP titled, Resident Alteration in Nutrition, was dated 9/24/09 and had documented on 8/17/10 that the resident had missing dentures.

A dental progress note dated 4/2/10 documented that the resident was seen for follow-up on his full lower dentures and that the resident was observed wearing both upper and lower dentures in comfort.

The Resident Activities of Daily Living Care Card (a form referenced by Certified Nursing Assistants to provide care to the resident) dated 7/12/10 had no documented evidence that the resident had dentures.

During a telephone interview with the resident's daughter on 9/14/10 at 11:30 am, she reported that the resident had been missing his dentures since July 4, 2010. She stated she knew this, because she had the information documented in a journal she kept for herself about her father.

There were no other nurse's notes about the resident missing his dentures, but on the date of 8/13/10 there was a nurse's note written about the resident having been reviewed by the weight loss committee. This note documented that the resident's dentures were missing, but there was no specific date written of when the dentures were lost. There was also no documented evidence of how long the resident's dentures were missing. It was then documented that the resident was to see the dentist for replacement of the dentures.

There was no documented evidence in the Social Service progress notes regarding when the resident's dentures went missing or of how long the resident's dentures were missing.

On 8/13/10 the Dental progress notes documented that the resident was seen for a denture impression and fit for new dentures, because the resident had lost his dentures.

The resident was observed on 9/14/10 at 1:00 pm napping in his bed, with no dentures in his mouth. The resident was next observed on 9/15/10 at 7:45 am sitting in a chair in his room, fully dressed in his day clothes, with no dentures in his mouth.

During an interview with the Licensed Practical Nurse on 9/15/10 at 7:55 am, she stated that the resident had dentures, but that they were missing now and she was uncertain how long they had been lost. She thought that that they had maybe been lost since April 2010.

The current Certified Nursing Assistant (CNA) and regular caregiver for the resident was interviewed on 9/15/10 at 12:15 pm and she stated, that she had been the resident's caregiver for the last couple weeks and that since she has been caring for him, he had not had any dentures.

During an interview with the Registered Nurse Unit Manager at 10:30 am, she stated she too was uncertain how long the resident had been missing his dentures. She stated that she recalled that the resident's dentures had been missing a while back, then they were found and then that they were missing again. She continued that she didn't know the date of when she was made aware of this last time that they went missing. She stated that because the most recent time the dentures were noted to have been lost, was not documented in the resident's medical chart, so she could not tell the surveyor the specific date of when this actually occurred.

10NYCRR 415.17(a-d)

Based on record review and staff interview during the recertification survey, the facility did not ensure that the Advanced Directives wishes of residents and/or their designated representatives were clearly documented for one (#108) of thirteen residents reviewed. Specifically, Advanced Directive information was not accurately completed for one resident. This resulted in no actual harm but has the potential for more than minimal harm. This was evidenced by the following information:

Resident #108
The resident was admitted to the facility on 8/26/10 with diagnoses of dementia, cerebrovascular accident, and diabetes mellitis. The Minimum Data Set (MDS) dated 9/1/10 assessed the resident as having short term and long term memory loss and moderately impaired decision making skills.

The resident's medical record revealed an identification sheet in the front of the chart stating that the resident was of do-not-resuscitate (DNR) status. However, there was no completed Resident Statement on Resuscitation (for a resident who lacked capacity), signed by two concurring physicians.

The physician's admission history and physical dated 8/26/10 identified that the resident was of DNR status, but there was no documented evidence that this resuscitative status was ever discussed and verified by the physician, with the resident's family to determine if this indeed was the resident's wishes.

A Social Service progress note dated 9/11/10 documented that the resident was of DNR status, with no health care proxy in place. It documented that the resident lacked capacity to complete a DNR. There was no documented evidence in the Social Services section of the resident's chart that DNR status had been discussed with the family to determine the resident's resuscitative wishes.

Additionally, there was no documented evidence in the nurse's notes that DNR status had been discussed with the family to determine that this status was in fact what the resident wished.

During an interview with the Registered Nurse Unit Manager (RNUM) on 9/15/10 at 10:30 am, she stated that she recalled that on the day of the resident's admission to the facility, the Admissions Coordinator had brought the resident's son to unit and made her aware that the resident was of DNR status, per the hospital paperwork. She stated she never saw this paperwork, but that the son at this time indicated that he wanted the resident to continue with DNR status in the nursing home. The RNUM stated that she should have completed the Resident Statement on Resuscitation, and should have gotten it signed by two concurring physicians on that day, since the son had been in the building at that time. She stated she directly contacted the physician for a telephone order for the DNR and had not completed the required paperwork and documentation as she should have done. She stated that she was responsible for completing weekly audits on her unit for resident Advanced Directives to make sure that everything was appropriate. The RNUM stated that she must have missed that this resident's DNR documentation and paperwork had never been completed.

10NYCRR 415.3(e)(2)

Based on observation, medical record review and staff interview, during the standard recertification survey, the facility did not ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities for one (#107) of five residents reviewed. Specifically, the facility did not ensure the replacement of the resident's hearing aids, in a timely manner. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced by:ne
Resident #107
The resident was admitted on 10/12/07 with diagnoses of dementia with behavioral disturbance, diabetes mellitis, and hypertension. The Minimum Data Set (MDS) dated 6/24/10 assessed the resident as having short term and long term memory problems and moderately impaired decision making skills. The MDS dated 2/11/10 assessed, the resident as having highly impaired hearing. It also assessed the resident as having used a hearing aid during the seven days prior to completion of the MDS.

A Comprehensive Care Plan (CCP) titled, Alteration in sensory perception as evidenced by decreased auditory acuity related to being very hard of hearing, was initiated on 6/30/08 and last updated on 9/22/09. This CCP stated that the nurse was to put the resident's hearing aids in every morning on the 7:00 am to 3:00 pm shift and to remove the resident's hearing aides every night at the hour of sleep. Additionally, it was noted that the hearing aids were to be kept in the medication cart during the hours of sleep.

The resident's Activity of Daily Living Card (a form used by the Certified Nursing Assistants (CNA) to provide care), dated and last revised on 7/12/10, documented that the resident was confused at times and was very hard of hearing.

The Medication Administration Record (MAR) for April 2010 documented, that the resident's hearing aides were to be placed in his ears at 7:00 am and taken out at 7:00 pm. Beginning on 4/3/10 the licensed practical nurses (LPNs) were signing their initials on the MAR at the 7:00 am and 7:00 pm hours, but had begun circling their initials (a circle means the procedure was not done). The back of this MAR first documented on 4/3/10 at 8:00 pm that the resident's hearing aides were missing. On 4/4/10 at 8:00 am, it was documented on the MAR that the resident's hearing aids were misplaced and that the family was called by the 7:00 am to 3:00 pm supervisor. On 4/5/10 at 8:00 am, it was documented on the MAR that the hearing aids were still missing. Lastly, on 4/8/10 at 9:00 am, it was documented on the MAR that the hearing aides continued to be missing and that the Registered Nurse Unit Manager (RNUM) was aware.

There was no documented evidence about hearing aide placement and removal on the MARs for May 2010, June 2010, July 2010, August 2010, and September 2010.

There was no documented evidence of nurse's notes from 5/9/10 to 9/3/10, in the medical chart documenting that the resident's hearing aides were missing.

A Social Service progress note dated 8/17/10 documented, that the resident had a decline in cognitive ability, as well as in ability to verbally communicate with staff and residents. It was written that this change could be attributed to more than one cause. It was then documented that the resident had displayed a progression in his dementia diagnosis and was unable to keep his hearing aides in place to facilitate communication.

An physician's interim order dated 8/24/10 was written for a hearing evaluation to be completed.

The resident was observed to be napping in his room on 9/14/10 at 1:00 pm, with no hearing aides in his ears. The resident was again observed in his room on 9/15/10 at 7:45 am, but at this time he was sitting in a chair fully dressed for the day, with no hearing aides in his ears.

During an interview with the regular day shift LPN on 9/15/10 at 10:35 am, she stated that the resident's hearing aides had been missing for quite some time. She stated that the LPNs had been signing them out of the medication cart at 7:00 am and signing them back into the medication cart at 7:00 pm, but stated that the resident did have a habit of taking his hearing aides out during the course of the day. She stated that the resident had not had hearing aides in his ears since April 2010. She stated she believed the RNUM had been made aware, but couldn't remember when she was told. When asked why it had taken so long for the facility to work on getting new hearing aids for the resident, she stated she had no idea and that she was not involved in arranging for this.

During an interview with the RNUM on 9/15/10 at 10:30 am, she stated that the resident's hearing aides had been missing for longer than she was actually aware. She stated she only discovered how long they had been missing after she reviewed the resident's MAR and found that they had been missing since April 2010. She stated that when she was made aware of them missing, she put in for the resident to get a hearing evaluation and received a physician's order for such on 8/24/10. She stated that she had never put resident hearing aides on the ADL care cards before, since the LPNs were the staff responsible for the placing the hearing aides in and taking them out.

During an interview on 9/15/10 at 12:15 pm with the facility's appointment scheduler, she stated she was going to schedule the resident's hearing evaluation on this date of 9/15/10 with the audiology department at the hospital. She stated that this was delayed some because she had to speak with the resident's daughter first, because she had to coordinate this appointment with another outside appointment the resident needed. She stated that she spoke to the daughter and that it usually took about a week from the time of scheduling for the appointment to occur.

10NYCRR 415.12(3)(b)

Based on observation, staff interview and record review, it was determined that the facility did not install self-closing devices on all door openings in smoke barriers, during the standard recertification survey. 2000 NFPA 101 section 19.3.7.6 requires that doors in smoke barriers shall be self closing or automatic closing. Specifically, not all doors in 2 of 4 smoke barriers were self closing. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced with the following:

Record review of the facility floor plan on 09/15/2010 revealed, the locations of the smoke barrier walls.

Observation of the North unit smoke barrier and South unit smoke barrier on 09/15/2010 at 11:30 am, revealed the unit side doors to the beauty shop and to the Glass Room were not self closing.

During an interview with the Maintenance Director on 09/15/2010 at 11:30 am, concurrent with survey observations, revealed acknowledgement of the observations noted above.

2000 NFPA 101 19.3.7.6; 1997 NFPA 101 13-3.7.6; 10 NYCRR 415.29, 711.2(a)(1)

Based on staff interview and record review, it was determined that the facility did not conduct fire drills on a random basis, during the standard recertification survey. 2000 NFPA 101 Life Safety Code section 19.7.1.2 indicates that fire drill shall be scheduled on a random basis. Specifically, the fire drills were conducted in a predictable pattern. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy. This was evidenced as follows:

Record review of the Facility Survey Report and the facility's fire drill evaluations for the previous four quarters on 09/15/2010 revealed, that the 11:00 pm to 7:00 am shift fire drills were always conducted within the same 45-minute period of the day.

During an interview with the Maintenance Director on 09/15/2010 at 9:05 am, revealed acknowledgment of the times fire drills were conducted.

2000 NFPA 101 19.7.1.2; 1997 NFPA 101 13-7.1.2; 10 NYCRR 415.29, 711.2(a)(1)

Based on observation, staff interview and record review, it was determined that the facility did not maintain the integrity of 1 of 1 smoke barriers observed, during the standard recertification survey. 2000 NFPA 101 section 19.3.7.3 requires that smoke barriers shall have a fire resistance rating of not less than 1/2 hour. Section 8.3.6 requires that space between pipes, conduits, cables, wires, air ducts and similar building service equipment passing through smoke barriers, shall be filled with a fire rated material that is capable of maintaining the smoke resistance of the smoke barrier. Specifically, the penetrations in North unit smoke barrier were filled with materials that did not maintain the fire rating of the wall. This resulted in the potential for more than minimal harm that was not immediate jeopardy. This was evidenced with the following:

Record review of the facility floor plan on 09/15/2010 revealed the locations of the smoke barrier walls.

Observation of the North unit smoke barrier on 09/15/2010 at 11:30 am, revealed a 6 inch by 6 inch section of missing drywall and extensive use of materials that did not have a fire resistance rating to fill penetrations and spaces.

During an interview with the Maintenance Director on 09/15/2010 at 11:30 am, concurrent with survey observations, revealed acknowledgement of the 6 inch by 6 inch section of missing drywall as noted above.

2000 NFPA 101 19.3.7.3, 8.3; 1997 NFPA 101 13-3.7.3, 6-3; 10 NYCRR 415.29, 711.2(a)(1)