Edna Tina Wilson Living Center

Based on observations, record reviews, and staff interviews, it was determined that the facility did not ensure that the resident's environment remained as free of accident hazards as possible. One of two resident suites reviewed for accidents and hazards contained an electric four-burner stove that was not safeguarded from the resident in the suite or the potential wandering residents who could walk into the room and turn on the stove. This affected Resident #25, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by, but not limited to, the following:

Resident #25 has diagnoses including Alzheimer's dementia. The Minimum Data Set Assessment, dated 9/16/10, revealed that the resident's ability to make daily decisions is severely impaired and that there are long and short term memory problems. The resident's documented profile reveals that the resident's verbal language communication skills show expressive aphasia (impairment of speaking language), and staff are directed to anticipate needs.

During the initial tour 11/8/10 at 10:40 a.m. and at 2:10 p.m., Resident Room #132 was observed to have a four burner electric stove and oven unit located to the immediate right of the entry door and visible from the hallway. The surveyor turned the knobs on the electric stove's heating elements and it worked. When interviewed at this time, the Registered Nurse/Nurse Manager (RN/NM) said that the stove and oven unit works.

Interviews conducted on 11/8/10 include:

1) At 2:45 p.m., Licensed Practical Nurse (LPN) #1 said that the residents that used to wander into Room #132 are no longer at the facility.

2) At 3:15 p.m., in the presence of the Administrator and Director of Nursing (DON), the burner knob was turned on for one of the four burners and heat radiated from it, thus confirming that the stove was functional.

3) At approximately 3:20 p.m., a maintenance staff member led a surveyor to Room #215-C, where electrical panels were located on the wall. When opened, the circuit breaker box displayed a list of individual functions for each electrical circuit, which included Respite Range #70, and #72. The maintenance staff member then switched this breaker from "on" to "off."

4) At 3:30 p.m., the Administrator said she was told the stove was not functioning. At that time, the Senior DON said there was no policy for the use of the stoves, but there is a switch that can be turned off or on when the family visits.

5) At 3:40 p.m. in the resident's room with the Senior DON, the DON, and the Administrator, the electric stove was checked and working. They said the family was in on Sunday (11/7/10), and when the family comes in they occasionally cook.

6) At 3:40 p.m., LPN #2 said that about a month ago during her shift a resident from another unit was found sitting on the couch in Room #132.

7) At 3:45 p.m., the RN/NM said that the resident could use the stove independently but she would need to be set up by the staff. She added that the resident's family uses the stove, but she was not sure how often.

During an observation on 11/9/10 at 12:15 p.m., the knobs that controlled the stove and oven were no longer on the stove.

[10 NYCRR 415.12(h)(1)(2), 415.29(a)]

Based on observations and resident and staff interviews, it was determined that for 3 of 23 residents reviewed for personal privacy, the facility did not provide care and services to ensure a resident's personal privacy was maintained. The issues involved body exposure during care and physician (MD) visits conducted in common living areas. This affected Residents #4, #17, #36, and four additional residents receiving podiatry care, and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and was evidenced by the following:

1. Resident #17 has diagnoses including dementia. The 8/19/10 Minimum Data Set (MDS) Assessment revealed that the resident is totally incontinent of the bowels and occasionally incontinent of bladder and requires the assistance of one for personal hygiene cares.

During an observation of toileting on 11/9/10 at 11:45 a.m., the Certified Nursing Assistant (CNA) assisted the resident to the bathroom for toileting. At this time, the resident asked the CNA to leave the bathroom door open, which she did. After toileting, the CNA stood the resident at the grab bar on the wall which exposed the resident's bare buttocks while the resident was cleansed of urine and stool. This occurred in full view of Resident #36, her roommate, and a visitor. During these cares, the visitor came to the open bathroom door and attempted to hand the CNA some linen to dispose of in the bathroom.

During an interview on 11/10/10 at 11:25 a.m., Resident #36 stated that she had not been asked if she wanted her curtain closed, and the visitor had not been asked to leave the room for a short time while Resident #17 was receiving cares.

In an interview on 11/10/10 at 12:20 p.m., the CNA said she had not asked Resident #36 if she wanted her curtain closed because she usually does not want the curtain closed. She did not think to ask the visitor regarding shutting the privacy curtain or stepping out of the room for a short period.

During an interview on 11/10/10 at 10:30 a.m. and again on 11/12/10 at 8:30 a.m., the Nurse Manager said that if a resident requests that the bathroom door remains open while they receive cares, she would expect staff to shut the privacy curtains for the roommate, and if a visitor was present, ask the visitor to step out of the room.

2. Resident #4 has diagnoses including chronic renal failure and a history of osteomyelitis of the right heel. The MDS Assessment, dated 6/3/10, revealed that the resident has independent cognitive skills for daily decision making.

Observations and interviews conducted on 11/10/10 include the following:

a) At 9:50 a.m., the podiatrist was cutting Resident #4's toenails in a small hallway off the living room. The door to this area was open and allowed full view of the procedure by all who walked by the area. Four additional residents arrived for podiatry care and observed each other receive treatments over the next half hour.

b) At 10:20 a.m., the Licensed Practical Nurse stated that it has always been done that way as it is quicker. While the podiatrist is treating one resident, nursing staff bring the next resident to the other end of the hallway adjacent to the other living room area and get them ready.

c) At 10:30 a.m., the Nurse Manager stated that the doors to the hallway should not be left open during podiatry visits to ensure the resident's privacy.

d) At 10:40 a.m., the podiatrist stated that he has always treated the residents'nails in the hallway and that a treatment room was never offered.

e) At 11:00 a.m., Resident #4 stated that he always gets his nails cut in the hallway off the living room.

f) At 2:40 p.m., the Director of Nursing stated that the physician's office could be used as a treatment room.

[10 NYCRR 415.3(d)(1)(i)]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not provide a compliant automatic sprinkler system. The issue was related to obstructions to sprinkler head spray patterns. This affected portions of three (Victorian, Mission, and Country) of three resident sleeping units, and resulted in a pattern of no actual harm with the potential for more than minimal harm that is not immediate jeopardy. The findings are:

During the initial tour of the resident environment on 11/8/10 from 1:45 p.m. to 3:00 p.m. and on 11/9/10 from 8:40 a.m. to 9:20 a.m., observations revealed the following areas contained sprinkler heads that were obstructed by ceiling mounted devices located in close proximity to the sprinkler heads:

1. In the closet of Room #309 (Mission Suite), the sprinkler head's deflector plate extends down 1.5-inches from the ceiling and is located 4 inches from an approximately 12-inch diameter ceiling mounted light fixture that extends down 3 inches from the ceiling.

2. In Room #308-B storeroom (Mission), the sprinkler head's deflector plate extends down 1 inch from the ceiling and is located 6 inches from a rectangular ceiling mounted light fixture that extends down 3 inches from the ceiling in the center of the room.

3. In Shower Room #225-B (Country), the sprinkler head's deflector plate extends down 1 inch from the ceiling and is located 7 inches from a rectangular ceiling mounted light fixture that extends down 3 inches from the ceiling in the center of the room.

4. In the linen closet (#226-Country), the sprinkler head's deflector plate extends down 1-inch from the ceiling and is located 5.5 inches from the ceiling mounted light fixture that extends down 3-inches from the ceiling in the center of the room.

5. In Shower Rooms #215-A and #215-B (Country), the sprinkler heads' deflector plates extend down 1 inch from the ceiling and are located 10 inches from a rectangular ceiling mounted light fixture that extends down 4 inches from the ceiling in the center of the rooms.

6. In the galley of the Victorian Unit, a sprinkler head's deflector plate extends down 1 inch from the ceiling and is located 3 inches from a ceiling heat detector that extends down 2.5 inches from the ceiling in the center of the space. This would partially obstruct the portion of the spray pattern that would cover the stove.

7. In storeroom #133-A (Victorian), the sprinkler head's deflector plate extends down 1 inch from the ceiling and is located 8 inches from a rectangular ceiling mounted light fixture that extends down 3 inches from the ceiling in the center of the room.

8. In Room #133-C (Victorian), the sprinkler head's deflector plate extends down 1.5 inches from the ceiling and is located 8 inches from a rectangular ceiling mounted light fixture that extends down 3 inches from the ceiling in the center of the room.

9. In shower room #125-B (Victorian), the sprinkler head's deflector plate extends down 1 inch from the ceiling and is located 8 inches from a rectangular ceiling mounted light fixture that extends down 3.5 inches from the ceiling in the center of the room.

10. In shower rooms #115-A and #115-B (Victorian), the sprinkler head's deflector plates extend down 1 inch from the ceiling and are located 8 inches from rectangular ceiling mounted light fixture that extends down 4 inches from the ceiling in the center of the rooms.

The 1999 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, requires that when the distance between a standard pendent sprinkler head is less than one foot from an obstruction, then the obstruction cannot extend any lower than the sprinkler head.

An automatic sprinkler system throughout the building is required due to the construction type (Type V (000)).

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.1.6, 19.3.5.1, 9.7.1.1; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-1.6.2, 13-3.5.1, 7-7.1.1; NFPA 13 1999: 5-6.5.1.2]

Based on observations, record review, and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain emergency lighting. The issue was related to battery powered emergency lighting that was not tested annually for a duration of 1.5 hours. This affected the entire building including three (Victorian, Mission, and Country) of three resident sleeping units, and resulted in no actual harm with the potential for minimal harm that is widespread. The findings are:

Observations on 11/9/10 at 9:30 a.m. revealed there is battery powered emergency lighting mounted to the wall in the generator room (Room #606A). A review of facility records pertaining to the emergency generator on 11/9/10 at 11:20 a.m. revealed the emergency lighting in the generator room is tested monthly, but there was no documentation that the lighting was tested for a duration of 1.5 hours on an annual basis. Subsequent interviews with the Director of Facilities Engineering Management and the Life Safety Specialist revealed they were not aware of a 1.5-hour test for the emergency lighting.

The 2000 edition of NFPA 101, Life Safety Code, requires that a functional test shall be conducted on every required emergency lighting system at 30-day intervals for not less than 30 seconds. An annual test shall be conducted on every required battery-powered emergency lighting system for not less than 1.5 hours. Equipment shall be fully operational for the duration of the test. Written records of visual inspections and tests shall be kept by the owner for inspection by the authority having jurisdiction.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.2.9.1, 7.9.2.3, 7.9.3; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-2.9, 5-9.2.3, 5-9.3]