Huntington Hills Center for Health and Rehabilitation

Based on record reviews and staff interviews during the recertification survey, the facility did not ensure that Accident/Incidents (A/I) Reports were thoroughly investigated for 4 (Residents #18, #25, #26 and #27) of 5 records in a total of 30 sampled residents and 3 out of sample records reviewed for A/I (Residents #37, #38 and #26). This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to::

1) Resident #37 has diagnoses that include but are not limited to Senile Dementia.

The A/I Report dated 8/2/11 at 8:00 AM documented that the Certified Nursing Assistant (CNA) noted an ecchymosis on the back of the resident's right hand area prior to administering the resident's morning care. The A/I report also documented that the resident stated that she does noes not know what happened.

The A/I Report contained an Investigation Questionnaire Section II that documented that the resident required a two-person assist for transfer with an Invacare lift. The A/I Report contained a statement of the CNA that worked on 7/31/11 on the day shift and who reported the ecchymosis on the back of the resident's right hand area prior to administering the resident's morning care on 8/2/11 at 8:00 AM. The A/I report also contained a statement from a CNA that worked on 8/1/11 day shift, a CNA that worked on 8/1/11 evening shift and a CNA that worked on 8/1/11 into 8/2/11 night shift. There was no documented evidence that statements were obtained from the 2nd CNAs that assisted the transfer or cared for the resident on these previous shifts.

An interview with the Director of Nursing (DNS) was conducted on 10/25/11 at 11:30 AM. The DNS stated that she was responsible for reviewing all A/I investigations. The DNS stated that there was no need to obtain the second CNA statements to complete the investigation for Resident #37.

2) Resident #39 has diagnoses that include Dementia.

The A/I Report dated 9/11/11 at 11:00 PM documented that the CNA noted a right shin skin tear and right knee redness during the shift's rounds. The A/I report also documented that a statement from the resident could not be obtained secondary to Dementia.

The A/I Report contained an Investigation Questionnaire Section II that documented that the resident required a two-person assist for transfer with an Invacare lift. The A/I Report contained a statement of the CNA that worked on 9/11/11 on the night shift and who reported the right shin skin tear and right knee redness. The A/I report also contained a statement from a CNA that worked on 9/11/11 day shift, and a CNA that worked on 9/11/11 evening shift. There was no documented evidence that statements were obtained from the 2nd CNAs that assisted the transfer or cared for the resident on these previous shifts.

An interview with the DNS was conducted on 10/25/11 at 11:30 AM. The DNS stated that it was not necessary to obtain statements from other CNAs that cared for Resident #39 from the previous shifts.

3) Resident #26 has diagnoses that include but are not limited to Dementia.

The A/I Report dated 10/12/11 at 4:00 PM documented that a CNA reported to the Registered Nurse (RN) that the resident sustained a large ecchymotic area on the left wrist and hand. The A/I report also documented that a statement from the resident could not be obtained secondary to Dementia.

The A/I Report contained an Investigation Questionnaire Section II that documented that the resident required a two-person assist for transfer using a Gait belt. The A/I Report contained a statement of the CNA that worked on 10/12/11 on the day shift. Additionally, the A/I Report contained a Phlebotomist statement that a blood was drawn on the resident's right hand on 10/11/11 at 5:00 AM and that the resident was not combative. There was no documented evidence that statements were obtained from the 1st and 2nd CNAs that assisted the transfer or cared for the resident on the previous night and evening shifts. There was no 2nd CNA statement obtained that worked and assisted with CNA that found the large left wrist and hand ecchymosis on Resident #26.

An interview with the DNS was conducted on 10/25/11 at 11:30 AM. The DNS stated that there was no CNA statements obtained from the previous shifts.

The facility's policy for Resident Incidents and Accidents did not address how the investigation process is done for an injury of unknown origin.

415.4(b)(l)(ii)

Based on record reviews and resident and staff interviews during the recertification survey, the facility did not ensure that clinical records on each resident are maintain in accordance with acceptable professional standards and practices. This is evident in 3 of 4 residents reviewed for nutritional supplement intake in a total of 30 sampled residents. Specifically, Residents #6 and #22 had a Physician Order for Glucerna (a nutritional supplement) four times daily. Resident # 28 had a Physician's Order for 2 Cal HN (a nutritional supplement) four times daily. Residents #6, #22 and #28 had refused their nutritional supplements. There was no documented evidence that after three days of refusing the supplements that nursing alerted the dietary in a timely fashion for re-evaluation as per the facility policy. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1) Resident #6 has diagnoses that include Malignant Neoplasm of Pancreas.

The Minimum Data Set (MDS) Admission Assessment dated 10/13/11 documented the resident is independent in cognition.

The Physician Order dated 10/6/11 documented Glucerna 1.5 60 cubic centimeter (cc) by mouth (PO) four times daily (QID).

The Medication Administration Record (MAR) for October 2011 documented Glucerna 1.5 60 cc PO QID. The MAR also documented that the resident had refused Glucerna 14 times from 10/13/11 through 10/19/11.

2) Resident #22 has diagnoses that included Fracture Shaft Open Fibula with Tibia and Diabetes.

The Physician Order dated 10/13/11 documented Glucerna 1.5 60 cc PO QID.

The MAR for October 2011 documented Glucerna 1.5 60 cc PO QID. The MAR also documented that the resident had refused Glucerna approximately 9 times from 10/18/11 through 10/21/11.

There was no documented evidence in the nurses' note reviewed from 10/18/11 through 10/20/11 that dietary was alerted after three days that the resident had refused Glucerna.

A Nurse's Note dated 10/21/11 documented that the resident does not like the Glucerna and that dietary was made aware.

There was no documented evidence of a dietary note from 10/18/11 through 10/24/11 addressing the Glucerna refusal issue by the resident.

An interview with Resident #22 was conducted on 10/21/11 at 11:25 AM. The resident stated that she refused to take Glucerna because she was a having problem of not going to the toilet regularly since taking the Glucerna.

The Dietary Director was interviewed on 10/24/11 at 10:30 AM. The Director stated that she could not locate any dietary notes from 10/18/11 through 10/24/11 addressing the Glucerna refusal by the Resident.

3) Resident # 28 has diagnoses that included Senile Dementia and Cerebrovascular Accident (CVA)..

The MDS Admission Assessment dated 10/5/11 documented that the resident is moderately impaired in cognition.

The Physician Order dated 10/1/11 documented 2 Cal HN (a supplement) 60 cc PO QID.

The MAR for October 2011 documented 2 Cal HN 60 cc PO QID. The MAR also documented that the resident refused 2 Cal HN from 10/3/11 through 10/15/11, approximately 26 times.

There was no documented evidence in the medical record from 10/3/11 through 10/13/11 that dietary was alerted by nursing to re-evaluate in a timely fashion after three days that the resident refused the supplement.

The Nurse's Note dated 10/14/11 documented that dietary was made aware and that dietary will address it.

The facility's policy dated 10/2011 titled Two Cal HN Medication Pass program documented "...If the resident refuses three or more consecutive days, alert dietary (in writing) to re-evaluate. Contact the Physician or Nurse Practioner and document the refusal on the Medication Administration Record and Integrated Progress Note..." The policy documented also covers other supplements like Glucerna.

415.22(a)(1-4)

Based on record review and staff interview during the recertification survey, the facility did not ensure that when the facility discharges a resident under any circumstances specified in paragraph (a)(2)(i) through (v) of this section, the resident's clinical record must be documented. The documentation must be made by the resident's physician when transfer or discharge is necessary under paragraph (a)(2)(i) or paragraph (a)(2)(ii) of this section. This is evident in 1 of 3 closed records reviewed in a total of 30 sampled residents. Specifically, Resident #28's Discharge Instructions and Summary form and Physician's Orders did not contain the Physician's signature and date. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The finding is:

Resident #28 has diagnoses that included Senile Dementia and Transient Cerebral Ischemia.

The Physician Order dated 10/17/11 documented discharge home with follow up by primary physician in one week, controlled medication sent home with resident.

Resident #28 was discharged home on 10/18/11.

The Discharge Instructions and Summary Form and the Physician's Order Form did not contain the Physician's signature and date.

An interview was conducted with the Director of Nursing Services (DNS) on 10/25/11 at 11:30 AM. The DNS stated that copies of the discharge medication prescriptions should be on file but could not locate them.

The facility's outdated April/1999 policy titled Discharge From Facility documented "... Physician order required... Prescriptions as needed... Discharge instruction sheet completed by Interdisciplinary team..."

483.12(a)(3)

NFPA 99, Standard for Health Care Facilities section 16-3.3.2 requires that free standing nursing homes have a Type 2 Essential Electrical System unless they meet all of the requirements of the listed exception. The exception to 16-3.3.2 allows a Type 3 Essential Electrical Systems provided that the facility has specific written admitting and discharge policies and procedures that preclude the provision of care for any patient or resident who needs to be sustained on electrical life support, offers no surgical treatment requiring general anesthesia, and provides an automatic battery-powered system or equipment that will be effective at least 1.5-hours and otherwise in accordance with NFPA 101, Life Safety Code , and NFPA 70 , National Electrical Code , and that will be capable of supplying light of at least 1-foot candle to exit lights, exit corridors, stairways, nursing stations, medication preparation areas, boiler rooms, and communications areas. This system must also supply power to operate all alarms systems. NFPA 99 section 4-3.1.2.2 (a) (5) specifically requires that Local, master, and area alarms that are components of the medical gas warning system shall be powered from the life safety branch of the emergency system as described in Chapter 3, " Electrical Systems. "
In addition, NFPA 99 section 3-6.2.2.3 requires the design, arrangement, and installation of wiring for the Type 3 Essential Electrical System is in compliance with the requirements of NFPA 70, National Electrical Code. Article 700-6 (d) of NFPA 70 requires that a separate automatic transfer switch be provided for NFPA 70 Article 700 Emergency Stem loads (e.g., fire alarm, emergency lighting) only and that separate automatic transfer switches would be needed to serve Non- Article 700 loads (e.g., loads that are not essential to safety to human life such as Article 701 Legally Required Standby Systems loads and Article 702 Optional Standby Systems loads). NFPA 70 Article 700-9 (b) states that: Unless otherwise permitted in (1) through (4), wiring from an emergency source or emergency source distribution overcurrent protection to emergency loads shall be kept entirely independent of all other wiring and equipment. Wiring of two or more emergency circuits supplied from the same source shall be permitted in the same raceway, cable, box, or cabinet.
1. The normal power source wiring shall be permitted to be located in transfer equipment enclosures.
2. In exit or emergency lighting fixtures, wiring supplied from two sources shall be permitted.
3. In a common junction box, attached to exit or emergency lighting fixtures, wiring supplied from two sources shall be permitted.
4. The wiring within a common junction box attached to unit equipment, containing only the branch circuit supplying the unit equipment and the emergency circuit supplied by the unit equipment shall be permitted.
NFPA 70 Article 701 Legally Required Standby Systems are those systems required and so classed as legally required standby by municipal, state, federal, or other codes or by any governmental agency having jurisdiction. These systems are intended to automatically supply power to selected loads (other than those classed as emergency systems) in the event of failure of the normal source. Legally required standby systems are typically installed to serve loads, such as heating and refrigeration systems, communications systems, ventilation and smoke removal systems, sewerage disposal, lighting systems, and industrial processes, that, when stopped during any interruption of the normal electrical supply, could create hazards or hamper rescue or fire-fighting operations. The legally required standby system wiring shall be permitted to occupy the same raceways, cables, boxes, and cabinets with other general wiring.
NFPA 70 Article 702 Optional Standby Systems are intended to protect public or private facilities or property where life safety does not depend on the performance of the system. Optional standby systems are intended to supply on-site generated power to selected loads either automatically or manually. The optional standby system wiring shall be permitted to occupy the same raceways, cables, boxes, and cabinets with other general wiring.

1. Based on observations, document review (i.e., posted electrical panel schedules), and staff interviews during the recertification survey , the nursing facility was not provided with a NFPA 99 - Health Care Facilities and NFPA 70 - National Electrical Code conforming Type 3 Essential Electrical System. Emergency power and lighting in most areas was provided via a generator and the installation was not in full accordance with NFPA 70 - Article 700 Emergency Systems and NFPA 110 - Emergency Power Systems.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings include but are not limited to the following:
(a). During inspection of the building during the morning and afternoon of 10/19/11 and the morning of 10/20/11 it was noted that Article 700 - Emergency System wiring was not completely independent of all other wiring and equipment. For example:
- Emergency power panel board (EM-NC) located in a 1st floor electrical closet served both Article 700 - Emergency System loads (e.g., fire alarm control panel, exit lights, smoke dampers, medical gas master alarm panel in front lobby ) and Non-Article 700 - Emergency System loads (e.g., front vestibule heather fan motors, HVAC incremental units on 2nd floor).
- Emergency power panel board (EM 1NW) located in a 1st floor electrical closet served both Article 700 - Emergency System loads (e.g., exit lights, exit stair lights, exit access lighting, medical gas area alarm panel) and Non-Article 700 - Emergency System loads (e.g., corridor receptacles, HVAC incremental units).
- Emergency power panel board (EM 2NW) located in a 2nd floor electrical closet served both Article 700 - Emergency System loads (e.g., corridor lights, exit lights, smoke dampers) and Non-Article 700 - Emergency System loads (e.g., corridor receptacles, HVAC incremental units, receptacle for pantry refrigerator and microwave).
(b). On 10/19/11 at 1:45 PM, observation of the emergency power distribution system in the basement level of the facility and concurrent interview with facility Director of Plant Operations revealed that the facility only had a single automatic transfer switch (ATS) to serve both Article 700-Emergency System loads (e.g.., fire alarm system, exit lighting, nurse call system) and non-Article 700 loads (Article 701 and/or Article 702 loads such as Walk-in coolers, garbage compactor, boilers, HVAC incremental units).
(c). As per interview with the facility Director of Plant Operations on 10/20/11 at 9:40 AM, he was not aware that NFPA 70 required that Article 700-Emergency System loads had to be kept entirely independent of all other wiring and equipment that serve non-Article 700 loads. He said that he would inform the facility's Administrator concerning this issue and that the facility would probably request a waiver because it may not be feasible for the facility to correct this deficiency.
NFPA 99-1999 Standard for Health Care Facilities: 16-3.3.2, 3-6, 3-6.2.2.3, 3-4.1.1, NFPA 70-1999 National Electrical Code: Article 700, NFPA 110-1999 Standard for Emergency and Standby Power Systems
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.1.1. requires that any vertical openings, such as stairways, be enclosed or protected in accordance with section 8.2.5 and that construction of the enclosure shall have not have less than a 1-hour fire resistance rating.

1. Based on observations, the facility did not ensure that exit stairways are enclosed with at least one hour fire resistant rated construction. Reference is made to unsealed penetrations, an improperly sealed penetration, and a partially sealed penetration that were found in exit stair fire barrier enclosure walls.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to the following:

(a). On 10/19/11 at 9:30 AM, an approximately 5-inch long section of the top-of-wall assembly at Exit Stair 1 on the 2nd floor was found to have been only partially sealed (i.e., it was only sealed with mineral wool). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

(b). On 10/19/11 at 11:32 AM, an unsealed cable penetration was found in an exit stair enclosure wall of Exit Stair 6 on the 1st floor (vicinity of the MDS/QPI Office). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

(c). On 10/19/11 at 12:05 PM, an unsealed plumbing penetration was found in an exit stair enclosure wall of Exit Stair 7 on the 1st floor (vicinity of Room 166). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5.2
10NYCRR, 415.29 (a) (2

Life Safety Code section 19.3.7.3 requires smoke barriers to be constructed in accordance with section 8.3 and shall have a fire resistance rating of not less than \'bd-hour.

1. Based on observations, the facility did not ensure that smoke barrier walls were constructed to have at least a \'bd-hour fire resistance rating. Reference is made to unsealed and/or improperly sealed penetrations that were found smoke barriers that were inspected as part of this survey.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings include but are not limited to the following:

(a). On 10/19/11 at 9:37 AM, three (3) cable penetrations were found in a 2nd floor smoke barrier wall (vicinity of the conference room). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

(b). On 10/19/11 at 10:48 AM, a conduit penetration that was sealed with non-fire resistance rated materials (i.e., joint compound) was found in a 1st floor smoke barrier (in Room 111). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

(c). On 10/19/11 at 1:24 PM, two (2) unsealed cable penetrations and a small (approximately 1-inch diameter) hole were found in a basement level smoke barrier (above cross-corridor doors between the kitchen and the main storage room). As per concurrent interview with the facility's Director of Plant Operations, he would have this sealed with the appropriate firestopping materials as soon as possible.

NFPA 101-2000 Life Safety Code: 19.3.7.3, 8.3

10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.7.6 requires that all fire protection equipment and devices be maintained and tested in accordance with Section 4.6.12. Section 4.6.12 requires that all fire protection equipment and devices be maintained and tested in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. Life safety Code Section 9.7.5 requires that the sprinkler system be maintained in accordance with NFPA 25, \i Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems . NFPA 25 Section 2-1 requires that Table 2-1 be used to determine the minimum required frequencies for inspection, testing, and maintenance with the exception that valves and fire department connections shall be inspected, tested, and maintained in accordance with Chapter 9. NFPA 25 section 9-1 requires that Table 9-1 be used to determine the minimum required frequencies for inspection, testing, and maintenance. Table 9-1 requires that valves be inspected in accordance with 9-4.1.2 and 9-4.2.1. Section 9-4.2.1 requires that valves be inspected internally every 5 years to verify that all components operate properly, move freely, and are in good condition and section 9-4.1.2 requires that alarm valves and their associated strainers, filters, and restriction orifices shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary. In addition, Table 9-1 requires that dry sprinkler system valves be inspected in accordance with 9-4.3.1.4. Section 9-4.3.1.4 requires that Strainers, filters, restricted orifices, and diaphragm chambers shall be inspected internally every 5 years unless tests indicate a greater frequency is necessary.

1. Based on record reviews, observations, and staff interview during the recertification survey, the facility did not ensure that all fire protection systems were maintained, inspected, and tested in accordance with the requirements found in NFPA 25,\i Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. Specific reference is made to the requirement for the inspection and maintenance at least once every five years of the interiors of sprinkler system alarm and check valves.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings were:

(a). On the morning of 10/20/11, review of automatic fire sprinkler maintenance records for both wet- and dry- sprinkler systems revealed that there were no records that required testing and inspection of alarm valves and check valves were being performed at least once every five years.

(b). As per interview with the facility's Director of Plant Operations on 10/20/11 at 9:00 AM, he would contact the vendor who maintains the sprinkler system to find out if they have any additional records.
NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-1, Table 2-1, 9-1, Table 9-1
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.6.3 requires that doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 1 \'be-inch thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke. The requirement for doors to resist the passage of smoke applies to corridor doors in both sprinkler protected and non-sprinkler protected smoke compartments. In addition, corridor doors shall be provided with a means suitable for keeping the door closed that is acceptable to the authority having jurisdiction (e.g., doors shall be provided with positive latching hardware).

1. Based on observations and staff interview during the recertification survey, the facility did not ensure that all corridor doors were constructed of 1 \'be-inch thick, solid-bonded core wood or of construction that resists fire for not less than 20 minutes and were constructed to resist the passage of smoke.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding was:

On 10/19/11 at 12:29 PM, an approximately 12-inch by 12-inch air transfer opening was found in a 1st floor corridor door (e.g., the door to the I.T. Equipment Room in the central core). As per concurrent interview with the facility's Director of Plant Operations, he would either have the air transfer opening sealed or request a waiver.

NFPA 101-2000 Life Safety Code: 19.3.6.3.1
10NYCRR, 415.29 (a) (2)

2. Based on observations and interviews during the recertification survey, the facility did not ensure that all corridor doors were provided with approved positive latching hardware. Specific reference is made to the lack of positive latching hardware (e.g., automatic flush bolts).
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings were:

(a). Observations on the morning and afternoon of10/19/11 revealed that several doors in the facility lacked positive latching devices. Examples include, but are not limited, to the following: inactive leaves of the pair of double doors to the service rooms on the 1st and 2nd floors, 1st floor Adult Day Health Care Program patient locker room, 1st floor recreation storage room, and basement dietary storage area were not provided with automatic flush bolts or similar devices to ensure positive latching of the pair of doors (i.e., these doors were provided with manually operated concealed thumb latches).

(b). As per interview with the facility's Director of Plant Operation on 10/19/11 at 9:20 AM, he would inform the building's Administrator about this issue.

NFPA 101-2000 Life Safety Code: 19.3.6.3
10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.2.2.2.6 requires that any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm system, and the systems required by 7.2.1.8.2 shall be arranged to initiate the closing action of all such doors throughout the smoke compartment or throughout the entire facility. Section 7.2.1.8.2 requires that:
In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3, or where approved by the authority having jurisdiction, doors shall be permitted to be automatic-closing, provided that the following criteria are met:
(1) Upon release of the hold-open mechanism, the door becomes self-closing.
(2) The release device is designed so that the door instantly releases manually and upon release becomes self-closing, or the door can be readily closed.
(3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door release service in NFPA 72, National Fire Alarm Code.
(4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door becomes self-closing.
(5) The release by means of smoke detection of one door in a stair enclosure results in closing all doors serving that stair.

1. Based on observations and staff interview during the recertification survey, the facility did not ensure that only approved, automatic releasing, door holding devices were used on smoke barrier doors.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding was:

On 10/19/11 at 11:14 AM, a manually-operated mechanical door holding device was noted to be use on a 1st floor smoke barrier door. Specific reference is made to the door to the Volunteer's Office. As per concurrent interview with the facility's Director of Plant Operations, he would have this improper holding device removed as soon as possible.

NFPA 101-2000 Life Safety Code: 19.2.2.2.6, 7.2.1.8.2
10NYCRR, 415.29 (a) (2)

Life Safety Code section 9.1.2 requires that electrical wiring and equipment be in accordance with NFPA 70, \i National Electrical Code.

1. Based on observations and interview, the facility did not ensure that all manufacturers' instructions for electrically powered biomedical equipment are followed as per the requirements of NFPA 70, National Electrical Code.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding was:

On 10/19/11at 11:38 AM, an electrically powered Omnicycle brand Motorized Therapeutic Exercise system (exercise cycle for physical therapy use) that was labeled " GROUNDING RELIABILTY CAN ONLY BE ACHIEVED WHEN THIS EQUIPMENT IS CONNECTED TO A RECEPTACLE MARKED 'HOSPITAL GRADE " was improperly connected to a non-Hospital Grade electrical receptacle in the 1st floor Physical Therapy/Occupational Therapy suite . As per concurrent interview with the facility Director of Plant Operations, he was unaware of the requirement that this piece of equipment be connected to a Hospital Grade electrical receptacle. He said he would have a listed Hospital Grade receptacle installed in this location as soon as possible.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-3 (b)

10NYCRR, 415.29 (a) (2)
2. Based on observations and staff interview during the recertification survey, the facility did not ensure that access to electrical panels was not maintained to permit ready and safe operation and maintenance of such equipment.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The finding was:

On 10/20/11 at 8:05 AM in a 1st floor electrical closet, an equipment cabinet containing components of the public address system was found to have been improperly installed only 22-inches in front of emergency power system panel " EM-NC " . The National Electrical Code requires that the width of the working space in front of electric equipment be at least 30 inches.
As per concurrent interview with the facility's Director of Plant Operations, he will have the public address system equipment relocated so that it no longer blocks access to the above-mentioned emergency power panel.

NFPA 101-2000 Life Safety Code: 19.5.1, 9.1.2, NFPA 70-1999 National Electrical Code: Article 110-26 (a)

10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.1.1 requires any vertical openings be enclosed or protected in accordance with 8.2.5 and prohibits openings in accordance with 8.2.5.5.

1. 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.

An unprotected vertical opening (i.e. an open staircase) was found between the first and second floors. The design of this vertical opening does not meet all of the requirements of an atrium, or all of the requirements for a mezzanine, or other approved opening.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.1.1, 8-2.5, 8-2.5.5.

2. Based on observations, the facility did not ensure that all vertical opening were enclosed or protected in accordance with the Life Safety Code.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings were:

(a). On 10/19/11 at 9:08 AM, an unsealed cable penetration was noted in the shaft wall of a HVAC shaft located in the 2nd floor 2B Electrical Room. As per concurrent interview with the facility's Director of Plant Operations, he would have the penetration sealed.

(b). On 10/19/11 at 2:05 PM, an approximately 2-inch by 2-inch that a cable was run through was found in an elevator shaft wall (vicinity of the basement East Elevator machine Room. As per concurrent interview with the facility's Director of Plant Operations, he would have the penetration sealed.

NFPA 101-2000 Life Safety Code: 19.3.1.1, 8.2.5
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.3.2.6 requires that cooking facilities be protected in accordance with 9.2.3. Section 9.2.3 requires that commercial cooking equipment be in accordance with the requirements of NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. NFPA 96 requires that wet chemical extinguishing systems be maintained, inspected, and tested in accordance NFPA 17A, Standard for Wet Chemical Extinguishing Systems. NFPA 17A section 5-2.1 requires the monthly visual inspection of the extinguishing system and section 5-2.4 requires that the date the monthly inspection is performed and the initials of the person performing the inspection shall be recorded. The records shall be retained for the period between the semiannual maintenance inspections.ne
1. Based on observations and staff interview during the recertification survey, the facility did not ensure that fire suppression systems in food preparation areas were properly maintained in accordance with applicable NFPA standards.ne This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.ne
The finding was:
On 10/19/11 at 1:58 PM, the monthly inspection tag for the manual means of kitchen fire suppression system actuation had not been completed for the months of August, 2011 and September, 2011. As per concurrent interview with the facility's Director of Plant Operations, the required inspections were performed by his staff but were not recorded on the inspection tag and that he would ensure, going forward, that this information is recorded on the inspection tags.
NFPA 101-2000 Life Safety Code: 19.3.2.6, 9.2.3, NFPA 96-1998, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations: 8-2, NFPA 17A-1998 Standard for Wet Chemical Extinguishing Systems: 5-2
10NYCRR, 415.29 (a) (2)

Life Safety Code section 19.2.9.1 requires that the means of egress in health care facilities be provided with emergency illumination in accordance with section 7.9. Both section 7.9.1.2 and Article 700-12 of the National Electrical Code permit a delay of not more than 10-seconds when changing from one energy source to another. Section 700-16 of the National Electrical Code requires emergency lighting systems shall be designed and installed so that the failure of any individual lighting element, such as the burning out of a light bulb, cannot leave in total darkness any space that requires emergency illumination.

1. Based on observations, the facility did not ensure that emergency illumination was arranged so that there would not be a delay of more than 10-seconds for both bulbs in emergency lighting fixtures when changing from the normal power source to the emergency power source.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding was:

On10/20/11 at 8:10 AM, the exit discharge from an exit to grade from Exit Stair #5 was found to be illuminated by one compact fluorescent single bulb that was capable of energizing within 10-seconds of loss of normal power and by one High Intensity Discharge (HID) lighting fixture. HID lighting fixtures usually take more than 10-seconds to start once they are energized. As per concurrent interview with facility Director of Plant Operations, the HID fixtures that they use do take more than 10-seconds to energize and that he will have the HID fixture replaced by one that is capable of energizing within 10-seconds of loss of normal power.

NFPA 101-2000 Life Safety Code: 19.2.9, 7.9.1.2, NFPA 7-1999 National Electrical Code: Article 700-12, 700-16
10NYCRR, 415.29 (a) (2)

Life Safety Code Section 19.7.6 requires that all fire protection equipment and devices be maintained and tested in accordance with Section 4.6.12. Section 4.6.12 requires that all fire protection equipment and devices be maintained and tested in accordance with applicable NFPA requirements or as directed by the authority having jurisdiction. Life safety Code Section 9.7.5 requires that the standpipe system be maintained in accordance with NFPA 25, \i Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems .
1. Based on observations and record review, the facility failed to ensure that standpipes were maintained in accordance with NFPA 25.
This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy.
The findings were:

(a). On the morning of 10/20/11, the facility was unable to provide evidence that the standpipe was inspected, tested, and maintained in accordance with the requirements of NFPA 25, \i Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems . Specifically, the facility was unable to provide any evidence that required flow tests were conducted at the hydraulically most remote hose connection of each zone of a standpipe system to verify the water supply still provides the design pressure at the required flow. NFPA 25 section 3-3.1.1 requires that this flow testing be conducted at least once every 5 years.

(b). As per interview with the facility's Director of Plant Operations on 10/20/11 at 9:05 AM, he would contact the vendor who maintains the standpipe system to find out if they have any additional records.

NFPA 101-2000 Life Safety Code: 19.3.5.1, 9.7.5, NFPA 25-1998 Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems: 2-2.8, 3-1, Table 3-1

10NYCRR, 415.29 (a) (2)

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.

Time Limited Waiver - expires on date in which CMS regulations requiring all nursing homes to be fully sprinklered takes effect.

Automatic sprinklers are required under canopies that are not constructed of non-combustible materials and in which combustible materials are used and stored. Example is the exterior canopy on the 2nd floor outdoor lounge/resident smoking area.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-3.1.1, 8-2.5, 8-2.5.5.

Life Safety Code section 19.7.1.1 requires that health care facilities have a written fire protection plan for the protection of all persons in the event of a fire. Section 7.2.2 requires that the written health care facility fire safety plan to address the evacuation of smoke compartments.

1. Based on record reviews and staff interview during the recertification survey, the facility did not ensure the protection of all persons in the event of a fire and for their evacuation to areas of refuge.
This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding was:

(a) On the morning of 10/20/11, review of the facility fire plan and floor plans that identified the locations of smoke compartments revealed that the smoke barriers that serve the 1st floor are arranged so that the body of the Volunteer Office is in one smoke compartment but the only exit from this room opens into an adjacent smoke compartment. This arrangement would require the evacuation of these rooms in the event of a fire in either of the smoke compartments. The facility fire plan did not address the evacuation of this room in the event of a fire in either of the smoke compartments. The facility shall either reroute the smoke barrier or address this issue in their site specific fire plan.

(b). On the morning of 10/20/11, review of the facility fire plan and floor plans that identified the locations of smoke compartments revealed that the smoke barriers that serve the 2nd floor are arranged so that the body of the 2A Clean Utility Room and the 2C Clean Utility Rooms are in one smoke compartment but the only exits from these rooms opens into an adjacent smoke compartments. This arrangement would require the evacuation of these rooms in the event of a fire in either of the smoke compartments. The facility fire plan did not address the evacuation of this room in the event of a fire in either of the smoke compartments. The facility shall either reroute the smoke barrier or address this issue in their site specific fire plan.

As per interview with the facility Director of Plant Operations on 10/20/11 at 8:44 AM, he would notify the facility's Administrator concerning this issue.

NFPA 101-2000 Life Safety Code: 19.7.1.1, 19.7.2.2
10NYCRR, 415.29 (a) (2), 711.2 (a) (1) NFPA 101-1997 Life Safety Code:13-7.1.1, 7.2.2

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.

Two sets of exit access doors in the 1D Alzheimer's unit were painted to look like wooden shelves with books and wooden cabinetry.
483.70(a), 711.2(a)(1), NFPA 101-2000: 19-2.1, 7-1.10.1, 7-1.10.2.1.