Gurwin Jewish Nursing and Rehabilitation Center

Based on record review and staff interviews during the Recertification Survey, the facility did not ensure that the clinical record for one of thirty sampled residents reviewed was accurate and free of errors. Specifically, for Resident #2, errors were found in the Minimum Data Set (MDS) Assessments of 12/15/10 and 3/11/11, and in the resident's Physician Monthly Orders regarding psychotherapy after 3/26/10 through to the present time. This resulted in no actual harm with the potential for more than minimal harm that was not immediate jeopardy.

The findings are:

Resident #2 has diagnoses including Senile Dementia, Depression, Anxiety, Episodic Mood Disorder, and Bowel Incontinence.

Resident #2's MDS Assessment of 12/15/10 documented that no physical restraint devices were utilized for this resident, while her MDS Assessment of 3/11/11 documented that a trunk restraint was utilized daily.

Resident #2's MDS Assessment of 3/11/11 documented that the resident was always continent of bowel movements, while her MDS Assessment of 12/15/10 documented that she was always incontinent of bowel movements.

Resident #2's Psychotherapy Service Note of 3/26/10 revealed that the therapist had terminated such services on that date. Record review revealed that the resident's physician did not discontinued the monthly orders for Psychotherapy, and this service had continued to be ordered on a monthly basis, despite not being provided, from that time through 2/15/11.

The day shift Nurse Manager (a Registered Nurse) on Resident #2's unit was interviewed on 3/24/11 at 1:20 PM. She stated that the physician had made a error with regard to Resident #2's monthly orders, and should have written an order to discontinue the psychotherapy sessions based on the therapist's recommendation of 3/26/10.

The Director of Nursing and the Associate Director of Nursing were interviewed on 3/24/11 at 2:05 PM. They stated that after review, the MDS Coordinator had made errors as documented above on the MDS Assessments of 12/15/10 (should have documented the daily use of a trunk restraint) and 3/11/11( should have documented that the resident was always incontinent of bowel movements). The Director of Nursing stated that Resident #2's Physician should not have been signing monthly orders for almost a year that were inaccurate with regard to psychotherapy services, and that both the Physician and Nursing staff should have noted and corrected that error.

415.22(a)(1-4)

Based on observation and staff interview, tented light fixtures, as part of a required fire-rated ceiling assembly, were incomplete and missing pieces of fire-rated material. This was noted on three of four resident-use floors in the Schachne building.

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

The findings are:

On 3/25/11 between 9:30am- 12:00pm during the recertification survey, the facility was noted to utilize a fire-rated ceiling assembly to achieve a Type I (332) building construction. As part of this fire-rated ceiling assembly, corridor light fixtures are required to be tented with a fire-rated material above the drop ceiling. Examples of incomplete tenting and missing pieces of fire-rated material including but not limited to: two light fixtures in the vicinity of resident room 401, two light fixtures in the vicinity of Stair A, one light fixture in the vicinity of resident room 302 and one light fixture in the vicinity of the smoke barrier doors near resident room 117.

In an interview on 3/25/11 at approximately 10:35am, the Director of Engineering stated that he would check all the light fixtures for proper tenting and inservice all staff on maintaining the tented light fixtures.

483.70(a), 2000 NFPA 101: 19.1.6.2, 711.2(a)(1)

The above waiver is on file with this office. A repeat waiver is granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waiver(s) have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction.

Include your request for renewal of this waiver, or plan of correction in the space provided on this form.

K-38

Doors to janitor and electrical closets in the Gurwin Building and the Weinberg Pavilion swing 90 degrees into the corridors, and when fully opened, the doors to these rooms project more than 7 inches into the corridor.
483.70(a), 711.2(a)(1), 713-1.15(a)(8)
NFPA 101, LSC 2000: 7.2.1.4.4

The following requirements of The Life Safety Code have 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. Please indicate if the facility wishes that waiver(s) to be continued.

Include your request for renewal of this waiver, or plan of correction in the space provided on this form.

K-20

There are a total of approximately 946 separate improperly sealed plumbing and HVAC penetrations in floor and ceiling slabs identified by the facility. The plumbing penetrations come through the decking into a sheetrock wall above, and the HVAC piping come through the metal decking into the equipment above.
483.70(a), 711.2(a)(1), NFPA 101-2000:18-3.1.1, 19-3.1.1, 8.2.5