Dutchess Center for Rehabilitation and Healthcare

Based on observation, interview, and record review, the facility infection control program did not ensure that acceptable procedures were used to minimize the potential for the development and spread of infection. Specifically: 1) Certified Nurse Aide (CNA) was observed on Units 100 putting soiled linen and wet briefs in an open bag on the floor with strong urine odor coming from the bag. 2) In the room of Resident # 8, 2 open cartons of beverages were stored directly on the floor. 3) Residents on Contact Precautions who were cohabitation in the same room did not have adequate space between the beds. This was evident for 7 semi private rooms.

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

Findings include but are not limited to:

1) On 2/10/12 at 10:25AM, on Unit 200, in resident room 223, a CNA was observed putting soiled linen and wet briefs in an open plastic bag on the floor. A strong odor of urine was coming from the bag.

In an interview with the CNA at that time, she replied "they are in a bag aren't they".

2) During an interview with Resident #8 on 2/10/12 at 9:45AM, 2 open cartons of beverages were noted on the floor. When this resident was asked why the cartons were on the floor he replied," there is no where to put them".

In an interview with the LPN Unit Manager on 2/10/12 at 10:04AM, regarding the cartons on the floor in room 210, she replied that " we need a place to put them".

3) During environmental tour of the facility on 2/10/12 at 1:30PM, 7 semi private rooms in which 1 or 2 residents were on contact precautions, the beds were observed not to have adequate room between them. The resident rooms are: 105,109,119,223,309,311,315,326.

Interview with the Administrator at that time regarding the closeness of the beds, he was unable to give a reason as to why they are close.

The New York State Regulation for Standards for Nursing Home Construction Subpart 713-1.3 states"...no bed shall be closer than three (3) feet to a window , radiator, or an adjacent bed."

415.19(a)(1-3)
NYCRR 713-1.3(h)(7)

Based on interview and record review, the facility did not promptly respond to residents' concerns regarding short staffing addressed in a Resident Council group meeting.

This resulted in the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

On 2/6/12 at 9:00AM, during the initial tour, the following Certified Nursing Assistants (CNA) were observed on the 3 units:

- Unit 100 3 CNAs for 38 residents.
- Unit 200 3 CNAs for 32 residents.
- Unit 300 3 CNAs for 39 residents.

Interviews with residents during the survey revealed that there are a number of days when there is a shortage of CNA's on the units. The residents further stated they had problems with the facility's call bell response time, Hoyer lift transfers and toileting when there are not enough CNA's.

A review of a Resident Council meeting dated 9/8/11, under new business, revealed that residents complained that the facility was short staff. The residents were told that the Nurse/CNA Staffing schedule, call outs etc would be reviewed.

A review of subsequent Resident Council Minutes dated 10/27/11, 11/10/11, 12/8/11, and 1/2/12 had no documented response by the facility regarding the residents' complaint of short staffing.

A review of the facility's policy on nursing staffing ratios for days from 6AM - 2PM, for all the units, calls for a maximum of 5 CNA's on the unit and a minimum of 4 CNA's on the unit.

A review of the actual CNA staffing for February 1, - 10th, 2012 indicated that the facility had less than 4 CNA's on the following days:

- On 2/1/12 - 3 CNAs on Unit 200.
- On 2/4/12 - 3 CNAs on Unit 100 and 3 CNAs on Unit 200.

A review of the actual CNA staffing on January/2012 indicated that the facility had less than 4 CNAs on the following days:

- 1/1/12 - 3 CNAs on Unit 100, 3 CNAs on Unit 200 and 3 CNAs on Unit 300.
- 1/3/12 - 3 CNAs on Unit 100, 3 CNAs on Unit 200 and 3 CNAs on Unit 300.
- 1/6/12- 3 CNAs on Unit 100, 3 CNAs on Unit 200 and 3 CNAs on Unit 300.
- 1/7/12- 3 CNAs on Unit 100, 3 CNAs on Unit 200 and 3 CNAs on Unit 300
- 1/8/12 - 3 CNAs on Unit 200 and 3 CNAs on Unit 200.
- 1/9/12 - 3 CNAS on Unit 100 and 3 CNAs on Unit 200.
- 1/10/12- 3 CNAs on Unit 100 and 3 CNAs on Unit 200.
- 1/11/12- 3 CNA on Unit 100.
- 1/15/12- 3 CNAs on Unit 100.
- 1/22/12 - 3 CNAs on unit 200.

A review of the actual CNA staffing on December/2011 indicated that the facility had less than 4 CNAs on the following days:

- 12/3/11- 3 CNAs on Unit 100.
- 12/6/11 - 3 CNAs on Unit 100 and 3 CNAs on Unit 300
- 12/7/11- 3 CNAs on Unit 300.
-12/9/11- 3 CNAs on Unit 100.
-12/12/12- 3 CNAs on Unit 100.
- 12/13/11- 3 CNAs on Unit 100.
- 12/14/11 - 3 CNAs on Unit 100.
- 12/20/11- 3 CNAs on Unit 100 and 3 CNAs on Unit 300.
- 12/24/11- 3 CNAs on Unit 100 .
- 12/29/11- 3 CNAs on Unit 100.

In an interview with Director of Nursing on 2/10/12 at 11:00AM, she stated that the facility attempts to replace the CNA's that call in that they are not coming into work.

In an interview with the Administrator on 2/10/12 at 1:05PM, he revealed that he was aware of the resident complaints about staffing and has attempted to replace staff that call in that they are not coming into work.

415.5(c)(6)

Based on observations and interview, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and safe environment. Specifically, 1) Units 100 and 200 were noted to be odoriferous as well as the toilet room next to the elevator on Unit 100. 2) Shower room on Unit 100 had dirty towels and paper towels on the floor. The bariatric shower chair in this shower room was observed to have whitish slippery residue on the back netting of the chair. 3) Resident # 53's room was observed to be untidy, soiled linen and chux on the floor and dirty clothes under the bed. 4) 18 semi private resident rooms were observed to have the beds less than 3 feet from each other. This was evident on 3 of 3 facility units.

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

Findings include but are not limited to:

1) Observations on Units 100 and 200 on February 6, 8, 9, 10, 2012, at various times of day, revealed the environment to be odoriferous with smell of urine and feces.

Interview with the housekeepers on 2/10/12 at 10:45AM and 10:55AM on Units 100 and 200 respectively,revealed that they were unable to give a reason as to why these units have odors.

2) During environmental tour on 2/10/12 at 1:25PM, revealed that the shower room on Unit 100 had dirty towels, gloves and paper towels on the floor. The bariatric shower chair had whitish residue on the back netting of the chair. The toilet room located next to the elevator on this unit, had a strong odor of urine.

Interview with the Housekeeping Director at that time revealed he was unaware of these conditions.

3) 18 semi private rooms were noted to have the beds less than 3 feet apart. This was evident on 3 of 3 facility units. Rooms: 101,103,105,109,111,117,119,121,123,223,307,309,311,315,317,323,325,326.

Interview on 2/10/12 at !:45PM, with the Maintenance Director, Housekeeping Director and Administrator revealed that they were unable to give a reason as to why these beds are close together.

The New York State Regulation for Standards for Nursing Home Construction Subpart 713-1.3 states "...no beds shall be closer than three (3) feet to a window , radiator, and an adjacent bed."

415.29(c)(4)
NYCRR 713-1.3(h)(7)

Based on observations, record reviews and staff interviews, the facility did not ensure that proper disposal of controlled medications in tampered containers was performed to prevent possible diversion and that discontinued narcotic medications were not removed from the units in a timely manner for proper storage and/or destruction . This was evident for 2 of 3 facility units. (Units 200 and 300)

This resulted in a pattern for potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Complaint Intake #NY00111834

1. During a tour of the Unit 200 medication room on 2/09/12 at 8:50 AM, it was noted that a blister pack containing a Restoril (a sedative-hypnotic) 15 mg. capsule had been tampered and was being secured by a piece of tape. During an interview with the unit manager at this time, she stated that if the foil seal of the blister pack had not been completely removed, it was acceptable to secure it with a piece of tape.

Additionally, three blister packs of discontinued medications including three tablets of Valium 5 mg., 13 tablets of Valium 10mg. and 4 tablets of Xanax 0.5 mg. were found to be stored on the top shelf inside the narcotic cabinet. When the medication nurse was interviewed at that time, she stated that these medications should have been removed and returned to the nursing supervisor or the Assistant Director of Nursing (ADON) for proper storage in the nursing office. She stated that the discontinued medications are being counted every shift but she would not remember the total number of discontinued narcotics being stored in the cabinet.

Interview with the ADON on 2/09/12 at 9:30 AM revealed that the nurses must submit all discontinued narcotics as soon as possible to prevent loss or diversion.

2. Inspection of the Unit 300 medication room on 2/09/12 at 10:15 AM revealed that the blister packs of two tablets of Percocet (pain medication) had been tampered and were being secured by a piece of tape. Interview with the ADON at this time revealed that it is the facility policy that once the seal covers of the narcotic medications had been removed or tampered, they must be disposed according to facility procedure.

Interview with the Unit 300 medication nurse on 2/09/12 at 10:30 AM, revealed that she was not sure as to how many blister packs of discontinued narcotic medications are being stored inside the narcotic cabinet. The ADON acknowledged at this time that if a blister pack was missing, it maybe unnoticed until an inventory is conducted weeks or days later if the discontinued medications are not submitted in a timely manner for destruction.

415.18(c)(2)

Based on interview and record review the facility did not ensure that a care plan was developed to address an alteration in urinary elimination. Specifically, a resident who required the insertion of an indwelling Foley catheter for urinary elimination 7 days admission did not have a care plan with measurable goals and objectives for catheter care and removal of the catheter. This was evident for 1 of 11 residents reviewed for indwelling catheter. (# 191).
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

A review of the entry record (MDS 3- assessment) revealed that this resident was admitted to the facility on 1/26/12.

A review of admission nursing assess of 1/26/12 that the resident did not have a catheter on admission .

Interview with the attending MD on 2/9/12 at 1PM revealed that the resident was admitted receiving diuretics. (Metolazone 2.5 mg on Tues and Thurs, Demadex 20mg od at 6:30AM and Demadex 20mg on Tues and Thurs with Metolazone.

A review of MD note of 2/2/12 revealed that the resident's abdomen was distended and an abdominal x-ray was done to r/o (rule out) the cause of distention"bladder distention vs constipation". The x-ray was negative for obstruction and impaction. The resident was unable to void.

A review of comprehensive care plans indicated no care plan for alteration in urinary elimination.

A review of MD orders revealed an order of 2/2/12 for straight cath for abdominal distention; if more than 400 cc's of urine was obtained a foley catheter was to be inserted.

Interview with the attending MD on 2/9/12 at 3:15PM revealed that the catheter was being removed for a voiding trial in 7 days.

Interview with Licensed Practical Nurse Unit Manager, on 2/10/12 at 9:45 AM, as to why there was no care plan for alteration in urinary elimination revealed that she had not "gotten to it yet".

415.11(c)(1)

Based on interview and record review the facility did not revise a care plan . Specifically a care plan for a resident receiving medication to alleviate pain was not revised after the time parameters for administering pain medication were changed. This was evident for 1 of 6 residents reviewed for pain (# 191).
This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident # 191 has an entry record (MDS -assessment ) indicating that she was admitted on 1/26/12.

A review of admission nursing assessment of 1/26/12 revealed that the resident had frequent pain, moderate with intensity of 7.

A review of admission orders revealed an order for Percocet 5/325mg - 1 tab q (every) 8h (8 hours) prn \ pain.

The comprehensive Care Plan for pain was not in the resident's record, but was found in the Unit Manager's office on Unit 200.
ne Interview with the attending MD on 2/9/12 at 1:15 PM revealed that the resident told her on 2/2/12 that the Percocet 5/325mg- 1 tab was " not always effective for 8 hours". The MD stated that she increased the Percocet to every 6 hours as necessary for pain .

The care plan was not revised to reflect the change in parameters for administration of Percocet (from every 8 hours to every 6 hours as necessary for pain).

Interview with Licensed Practical Nurse Unit Manager on 2/10/12 at 9:45AM as to why the care plan for pain was not in the record ; and had not been revised to reflect the change in medication times revealed that the care plan was in her office to be revised.

415.11 (c)(2)(i-iii)

Based on observation, and staff interview, the facility did not promote care for residents in a manner that maintains or enhances each resident's dignity; Specifically, the facility did not ensure that a resident was appropriately dressed. This was evident for 1 of 38 residents in the sample (Resident #49). This resulted in no actual harm with a potential for more than minimal harm that is not immediate jeopardy.

Findings are:

Resident #49 who has diagnosis of Dementia was observed on 2/6/12 at 11:00AM, in his room sitting in a wheel chair, dressed in long underwear with a pair gray shorts over the underwear. The resident was observed again in the dining room on 2/9/12 at 12:30PM wearing sweat pants in which the pant legs were too short for the resident.

In an interview with the Certified Nurse Assistant (CNA) on 2/8/12 at 1:30PM, she stated that the resident came to the unit with very few clothes. She had been taking clothes from the facility's lost and found to put on the resident.

In an interview with the Registered Nurse (RN) Unit Manager on 2/8/12 at 1:45PM, she stated that she was unaware that the resident needed clothing.

415.5 (a)

Based on interview and record review, the facility did not ensure that a resident who is mildly depressed and refusing care was provided medically related social services to address his behavior. This was evident for 1 of 38 sampled resident (Resident #173). This has the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 173, who is 65 years old, was admitted to the facility on 12/2/11 for rehabilitation services after hospitalization related to a fall. The resident's diagnoses include morbid obesity and arthritis.

According to the Minimum Data Set (an assessment tool) dated 12/3/11, the resident had an active discharge plan with no referral at that time.

The Social History dated 12/7/11 noted that the resident previously lived in a hotel. Upon reaching ambulation goals, and achieving decreased pain and weight loss the resident would like to return to the community.

The Comprehensive Care Plan (CCP) dated 12/2/11 noted that the resident's placement is short term. The discharge goals developed for the resident stated, "to be discharged appropriately upon completion of placement goals," and "will reside in the least restrictive environment once health goals are met". The interventions to achieve these goals were: regularly assess the resident potential discharge; identify and monitor progress of treatment goals; engage resident in discharge planning and provide emotional support/counseling to the resident in preparation for discharge or transfer.

On 12/13/11 the Psychologist evaluated the resident. The evaluation stated the following: "Patient presents with mild depressed mood, but with no recent acute symptoms. Patient generally participates in PT (physical therapy). Generally motivated with adaptive attitudes. No further sessions scheduled as patient does not appear to be struggling with mood or behavior . If the patient does deteriorate in mood or behavior will be available for follow-up."

On 1/6/12 the resident was discharged from rehabilitation services (both PT and OT [occupational therapy]) due to lack of progress. On 1/9/12 the social worker documented that the resident remained in bed all day and that his mood reflected minimal depression.

The CCP for discharge back to the community mentioned above was reviewed on 1/9/12 and reflected that it continued to be appropriate.

On 2/8/12 between 2:15 PM and 4:05 PM the dietitian and the social worker were interviewed regarding the resident progress towards achieving his discharge planning goals in order to return back to the community. The dietitian stated that the resident had refused repeatedly to participate in a Lifestyle Program to loose weight. The social worker was not aware that the resident had refused to participate in the Lifestyle Program and was not receiving psychological services. Therefore, no counseling was provided to the resident regarding his refusal of care.

415.5(g)(1)(i-xv)

Based on observation, interview and record review, the facility did not ensure that a resident was provided the appropriate care to prevent the development of a Stage 2 pressure and to prevent the development of additional pressure sores. Specifically: 1) weekly skin checks by a licensed nurse was not done prior to and subsequent to the development of the pressure sore and 2) a pressure relieving mattress or other pressure relieving device was not provided to the resident when it was evident that the resident was not consistently off loading his foot with regular size pillows. This was evident for 1 of 3 residents reviewed for pressure sores (Resident #173). This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 173, who is 65 years old, was admitted to the facility on 12/2/11 for rehabilitation services after hospitalization related to a fall. The resident's diagnoses include morbid obesity and arthritis.

The Minimum Data Set (an assessment tool) dated 12/3/11 revealed that the resident was admitted with no pressure sores, was at risk for the development of pressure sores, required extensive assistance with bed mobility and was nonambulatory.

The Comprehensive Care Plan (CCP) dated 12/2/11 noted the resident to be at risk for pressure sore as evidenced by limited out of bed schedule, obesity and incontinence . The interventions to address these risk factors included turning and postioning (T&P), elevate legs, assess skin condition daily during care and to encourage the resident to shift his weight when in bed.

A nurse's note written by an LPN on 1/6/12 showed that on that date the resident was observed with a Stage 2 pressure sore on his right heel, measuring 3.8 cm x 3.3 cm x 0.1 cm. The note also stated that the area had light red/pink granulated tissues without slough and no apparent drainage. At 6 o'clock of the wound had dark discoloration measuring 0.8 cm x 4.0 cm with dried edging.

On 1/11/12 the CCP was revised to include heel lift and strip of sheep skin at foot of bed to prevent contact with foot of bed surfaces. The CCP also noted that the resident was noncompliant with his plan of care including off loading his heels with the use of pillows.

A wound care note dated 1/19/22 showed that the pressure sore on that date measured 2.2 cm x <1 cm; resident is noncompliant regarding T&P schedule, and that the resident often shifted himself in bed resulting in his lower extremities falling of the pillows.

On 2/9/12 in the afternoon the LPN/Charge Nurse was asked how often the nurses are scheduled to do skin assessments on the resident. She stated, "Weekly." A review of the weekly skin assessment form revealed the following:

- 12/23/11 - rash on buttock
- 12/3011 - not done
- 1/6/12 refused
- 1/13/12 - not done
After 1/13/12 there was no more documentation to reflect weekly skin inspection by a licensed nurse.

Observation by the surveyor in the presence of the LPN/Charge Nurse on 2/9/12 at 2:10 PM revealed that the resident's right foot was not on the pillow but on the mattress. The other foot was also on the mattress which is very firm and hard. The sheep skin placed over the footboard did not cover over half the width of the footboard. The resident's right foot was in direct contact with the footboard. Blood was seen on the outside of the dressing and on the bed sheet. At that time the nurse noted that when the resident, who is bed bound by choice, shifts his weight, the pillows move from under the resident's feet. This results in the resident's heels/foot coming in direct contact with the mattress.

The wound was observed by a surveyor on 2/10/11 at 10:30 AM. The wound measured approximately 3.0 cm x 3.0 cm. with a small a small amount of drainage. This reflects an increase in size since the previous measurement of 2/3/12 which was 0.9 cm x <.01 cm.

Interview with the Director of Nursing on 2/10/12 in the afternoon, revealed that the resident will be provided with a alternating air mattress and that a larger size pillow for the resident's bed or securing the pillow to the bed was not considered.

415.12(c)(2)

Based on interview and record review, the facility did not ensure that a resident was provided the necessary pain management to attain the highest practicable physical well-being.
Specifically: 1) the resident's level of pain was not determined prior to and after administration of a narcotic used to address the resident's complaint of pain; and 2) the resident was not administered pain medication prior to receiving therapy although the resident complained of pain secondary to therapy. This was evident for 1 of 3 residents reviewed for pain management (Resident #173). This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 173 who is 65 years old was admitted to the facility on 12/2/11 for rehabilitation services after hospitalization related to a fall. The resident's diagnoses include morbid obesity and arthritis.

The Minimum Data Set (an assessment tool) dated 12/3/11 revealed that the resident was on pain medication as needed and that he had pain frequently that limited his activities.

The Comprehensive Care Plan (CCP) dated 12/2/11 noted that the resident had pain evidenced by verbalization, yelling out during transfer and cares and degenerative joint disease to both knees. The goal was for the resident's pain to decrease in severity within 2 hours of administration of medication for pain. The interventions listed to achieve this goal included: assess intensity of pain, also frequency and duration; use standardized scale observe for no verbal cues and assess for break through pain.

A review of the resident's physician orders revealed that the resident's medication regimen included the following:

- 12/2/21 Percocet 2 tabs every 6 hours as needed
- 1/2/12 Morphine Sulfate Contin 15 mg every 12 hours and to continue on Percocet 2 tablets every 12 hours as needed.
- On 1/28/12 Morphine Sulfate Contin was increased to 30 mg every 12 hours

According to the Medication Administration Record (MAR), Percocet was administered as follows for December 2011 with pain intensity assessment done using a pain scale of 1 -10:

- 12/08/12 at 10:30 AM
- 12/20/11 at 9:15 AM
- 12/25/11 at 5:30 AM
- 12/29/11 at 8:00 AM
- 01/01/12 at 10:00 PM.

However, the back page of the MAR for December 2011 showed that Percocet was administered as follows with no pain assessment done prior to or after administration of Percocet in accordance with the plan of care mentioned above.

12/09/11 at 11:30 AM
12/19/11 at 11:50 AM
12/27/11 at 10:30 AM

In addition, a review of the narcotic records for the months of December 2011 and January 2012 revealed that Percocet tablets were removed from the blister pack (package that contains the tablets of Percocet) multiple times (almost daily in December 2011) but not reflected on the MARs as being administered and assessed for its effectiveness.

Documentation by Physical Therapy and Occupational Therapy staff members revealed that the resident was discharged from these services on 1/6/12 due to lack of progress. On 2/8/12 at 3:05 PM the Director for Rehabilitation Services was interviewed. She stated that the resident's lack of progress was due to complaint of pain and lack of motivation. Subsequently, an interview with the Physical Therapy Aide on 2/9/12 at 3:45 PM revealed that the resident was provided therapy in the afternoon at about 3:00 PM.

According to the MARs for December 2011 and January 2012 and the narcotic record, the resident was not administered Percocet or any other pain medication close to 3:00 PM to minimize pain during therapy.

415.12

Based on interview and record review, the facility did not ensure that planned weekly wound assessments for a resident with a Stage 2 pressure sore was done by a Registered Nurse (RN)instead of a Licensed Practical Nurse (LPN). This was evident for 1 of 3 sampled residents reviewed for pressure sores. This had the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

Resident # 173, who is 65 years old, was admitted to the facility on 12/2/11 for rehabilitation services after hospitalization related to a fall. The resident's diagnoses include morbid obesity and arthritis.

A nurse's note written by an LPN on 1/11/12 showed that on that date the resident was observed with a Stage 2 pressure sore on his right heel, measuring 3.8 cm x 3.3 cm x 0.1 cm. The note also stated that the area had light red/pink granulated tissues without slough and no apparent drainage. The "6 o'clock" position of the wound had dark discoloration measuring 0.8 cm x 4.0 cm with dried edging.

Subsequently, weekly wound assessments notes were written by the above mentioned LPN. These notes were written on 1/19/12, 1/26/12 and 2/3/12. None of these notes were countersigned by a RN.

Interview with the LPN on 2/9/12 in the afternoon revealed that she accompanies the physician on wound rounds without the presence of a RN. According to the scope of practice for LPNs, they are not authorized to conduct assessments. No weekly assessments by a physician were noted in the resident's medical record.

415.11(c)(3)(ii)

Based on observation and interview it was determined that inadequate housekeeping practices were noted in the oxygen transfilling room and the laundry. The housekeeping conditions noted in these areas could contribute to a fire emergency.

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

The findings are:

1) On 2/7/12 at approximately 11:15 am the laundry was visited. Inspection of the areas behind the dryers and washers revealed accumulations of lint upon walls and floors. Further inspection found similar accumulations of lint atop equipment and particularly between adjacent equipment within narrow gaps, etc.

2) On 2/7/12 at approximately 11:45 am the oxygen transfilling room was inspected. The floor was littered with paper, plastic caps, dust accumulations, etc. This was particularly apparent at the floor periphery of the room.

In an interview at the time, the Director of Maintenance could not account for the conditions noted, but indicated that these areas would be cleaned and maintained in an orderly manner .

NFPA 101 , 2000 : 19.1.1.3
10NYCRR 711.2(a)

Based on observation and interview it was determined that the structural components of the building were not fire protected as required in one area of the building. This situation could result in damage in the event of a fire.

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

The findings are:

On 2/7/12 at approximately 1:00 pm the elevator machine room was inspected. The room was provided with a monolithic ceiling (sheetrock) and the room was sprinklered. Three access panels were noted in the ceiling and upper wall of this room. The Director of Maintenance stated at the time that the panels provided access to electrical conduit, etc. above the ceiling. Inspection of the area above the ceiling via these panels revealed structural beams, bar joists, etc. that were not sprayed , nor rendered fire resistive by other means. The protection of these structural elements was via the monolithic ceiling in the room. The access panels in place were of sheet metal construction and were not labeled as a fire rated assembly. Access panels are required to be of a fire resistive construction.

NFPA 101 , 2000 : 19.1.6.2
10NYCRR 711.2(a)

Based on observation and interview it was determined that 1 of 6 smoke barriers in the facility were not constructed to resist the passage of smoke and fire in the event of an emergency.

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

The findings are:

On 2/7/12 at approximately 2:15 pm the smoke barrier on the 1st floor between rooms 117 & 119 was inspected. It was noted that a heating, ventilation and air conditioning (HVAC) duct soffit passed through the smoke barrier on the resident room side of the corridor wall. Further inspection above the level of the suspended ceiling revealed that openings (8" x 8") into this soffit were present on both sides of the smoke barrier. The smoke barrier was not continued through the soffit and is not required to do so as the soffit constitutes an interstitial void passing through the barrier. However, the presenc e of the openings into this soffit constitutes a penetration of the smoke barrier.

The Director of Maintenance stated at the time that the openings were present to provide access to fire dampers located within the duct that was in the soffit. He further stated that this situation was also present on the floor above. Access openings to duct dampers are required to be protected by appropriate fire rated access door assemblies to provide protection for the smoke barrier and to allow required access to fire dampers.

NFPA 101 , 2000 : 19.3.7.3
10NYCRR 711.2(a)