Huntington Living Center

Based on observations, staff interviews, and record reviews, it was determined that for two of six observations of care, and for one of three units in the Geneva South building observed for the environment, the facility did not use appropriate infection control techniques or provide a safe, sanitary environment to prevent the potential transmission of infection. THIS IS A REPEAT DEFICIENCY FROM THE RECERTIFICATION SURVEY OF 10/22/09. Issues included the lack of handwashing and/or glove changing during provision of personal cares (Resident #53), improper storage and handling of soiled linen and trash on the third floor unit, and improper cleaning and disinfection of Resident Rooms #306, #310, #314, #318, #320, and #322, and the third floor unit shower room. This resulted in a pattern of no actual harm with potential for minimum harm that is not immediate jeopardy, and is evidenced by the following:

1. Observations made during the environmental tour on the third floor on 10/25/10 from 8:45 a.m. to 10:00 a.m. included the following:

a) The surveyor detected a strong urine odor upon entrance to the unit from the elevator. This urine odor was pervasive around the nursing station and in the hallways, and extremely strong around the dirty linen hampers in two halls and from the dirty utility room next to the nurses' station.

b) In Room #310, a strong urine odor emanated from soiled briefs that had been left in the resident's personal trash can.

c) In Room #314, an isolation linen hamper located in the bathroom was filled to the top, and a strong urine odor was evident.

d) In Rooms #306 and #322, strong urine odors were noted.

e) In Room #318, the trash bin was full, and dirty gloves were piled on the trash, falling off to the side and on the floor.

f) At 10:00 a.m., the dirty utility room door was open, and a strong odor of urine and feces was noted. A housekeeper was seen using a large piece of cardboard as a shovel to pick up dirty, loose briefs off the utility room floor.

g) In Room #320, the Nurse Manager (NM) stated that the resident is on isolation precautions for Methicillin Resistant Staphylococcus Aureus (MRSA) in his urine. Soiled bed linens were lying on the floor, and the room had a pervasive urine odor.

On 10/26/10 at 9:00 a.m., a urine odor was evident at the nursing station.

2. Resident #56 has diagnoses including Clostridium Difficile (C-Diff, intestinal infection), and a urinary tract infection. The undated Certified Nursing Assistant (CNA) plan of care revealed that the resident requires extensive assistance with care.

When observed for cares on 10/26/10 at 10:25 a.m. in the unit shower room, the resident was seated on a shower chair that had a commode bucket underneath. When the CNA removed the bucket from the commode chair, loose stool was observed in the bucket and on the rim. The CNA washed the resident's peri-rectal area, which soiled several washcloths with a large amount of stool. The CNA placed the soiled washcloths on the shower room floor. The CNA then placed the soiled commode bucket back on the shower chair and proceeded to transport the resident to her room. During an interview at this time, the NM reported that housekeeping is responsible for cleaning the shower rooms. The NM then asked the housekeeper to clean the shower room.

3. Observations made on 10/27/10 at 8:50 a.m. included the following:

a) The surveyor detected a strong urine smell on the unit upon exiting the elevator to the residential unit.

b) In Room #314, Resident #60 is on isolation precautions for C-diff. A dried 3-inch semi circular piece of fecal matter was seen on the floor on the left base of the grab bar in the bathroom. The NM could not say how long this had been on the floor.

c) In Room #310, a urine soiled bed linen was lying on the floor.

d) At 8:55 a.m., the unit secretary said the urine odor on the unit was from the dirty utility room, which is small and always full because there is no other place on the unit to put the dirty laundry. The unit secretary reported that the urine odors are always present.

e) At 9:20 a.m., the housekeeper opened the utility room door, which revealed numerous bags of dirty laundry and trash piled on the floor. When the door opened, the corner of the door hit a trash bag and tore a hole in the bag. A very strong odor was evident from the room. The housekeeper reported that the room is emptied in the morning, usually at 8:30 a.m. He did not know why it had not been done that day. He added that the urine odor in the hall was coming from the dirty linen bins and said there was no place to put the dirty linen until the utility room is emptied.

f) At 9:45 a.m., the NM and Director of Nursing opened the door to the utility room and the garbage bag tore further. They stated the isolation trash and linen is also placed in the dirty utility room.

g) At 10:00 a.m., the housekeeper stated he cleaned the shower room on 10/26/10 at the request of the NM but did not clean the floor or shower equipment with a bleach solution recommended for C-diff. He said he was told it ruins the floors. He revealed he used a solution called Virex to clean the floors and bleach to clean the grab bars. He did not know the effectiveness of the Virex product.

h) At 10:50 a.m., the Director of Environmental Services said the shower room and equipment used should have been cleaned with a bleach solution. He also said the Virex chemical is not effective against C-diff. At 2:30 p.m., the Environmental Services Supervisor, the infection control practitioner or the housekeeping supervisor, and NM were unable to locate policies for the cleaning of C-diff. When asked if there was any reference material on the unit for the housekeeper to refer to, they said no.

4. Resident #53 has diagnoses including cerebral vascular accident (stroke). The Minimum Data Set Assessment, dated 9/7/10, revealed that the resident requires extensive assistance of one for personal hygiene needs. The undated CNA care card and the 9/14/10 Comprehensive Care Plan included that the resident will need assistance with cares.

During observations of care on 10/26/10 at 9:35 a.m., the CNA cleansed the resident's rectal area with a moderate amount of feces noted. The CNA washed from front to back, repeatedly reaching forward and touching the resident's labia without changing to a new washcloth or folding over the washcloth. The CNA changed gloves without washing/sanitizing hands and touched the resident's clothing and items in the room, performed Range of Motion, opened a soda for the resident, completed mouth care, and brushed the resident's hair before washing/sanitizing hands.

Additionally, while completing care, the CNA placed visibly soiled linens and an incontinence brief at the foot of the bed on the resident's bedspread and blanket. While removing the soiled linen, the CNA dropped a washcloth visibly soiled with feces on the resident's pillow, removed the pillowcase, and dropped the washcloth again on the uncovered pillow. The CNA placed the pillow on top of the telephone on the bedside stand. When the linen soiled with visible feces and the brief were removed from the bed, a 6-inch round wet spot was noted on the resident's bedspread. The CNA made the bed with the wet spot folded underneath and folded the resident's soiled blanket and placed it on the foot of the bed.

When interviewed on 10/26/10 at 11:05 a.m., the CNA stated he would not usually change his gloves or wash his hands until he had completed care unless there was a large amount of feces. The CNA stated he was taught to wash his hands when he changes gloves but did not do it today because he was nervous. The CNA stated he placed visibly soiled linen at the end of the resident's bed but stated he should have used a bag to contain the linen.

When interviewed on 10/26/10 at 11:15 a.m., the Registered Nurse (RN) Manager stated she expects staff to wash hands every time gloves are changed and to change gloves and wash hands after incontinence care. She stated she expects staff to wash a resident's rectal area from front to back then fold the washcloth to a clean area and repeat twice, then change to a clean washcloth. The RN Manager stated she expects staff to place a barrier on the end of the resident's bed and place the soiled linen on it. The RN Manager and surveyor went to the resident's room at 11:27 a.m. and observed the resident's bed made with the soiled blanket folded at the foot of the bed and the wet area on the underside of the bedspread still visibly wet.

The facility policy entitled, "Incontinence Care," dated reviewed/revised 5/27/10, included after cleansing rectal area, remove soiled gloves and wash hands. When a facility policy on handling linen was requested, a chapter titled, "Guidelines for Handling Linens," from the "Lippincott's Textbook for Nursing Assistants," dated 2008, was provided but did not address these linen issues.

[10 NYCRR 415.19(a)(1-4)]

713-1.2 Nursing unit.

(c) Service areas. The service areas noted shall be located in or be readily available to each nursing unit. The size and disposition of each service area will depend upon the number and types of beds to be served. Although identifiable spaces are required to be provided for each of the indicated functions, consideration will be given to design solutions which would accommodate some functions without specific designation of areas or rooms. Details of such proposals shall be submitted for prior approval.

(4) Room for examination and treatment of patients. This room may be omitted if all patient rooms are single-bed rooms. This room shall have a minimum floor area of 120 square feet excluding space for vestibule, toilet, closets, and work counters, whether fixed or movable. The minimum room dimension shall be 10 feet. The room shall contain a lavatory or sink equipped for handwashing; a work counter; storage facilities; and a desk, counter, or shelf space for writing.

Based on observations and staff interview conducted at Huntington Living Center during the Recertification Survey, it was determined that the facility did not maintain compliance with Subpart 713-1 Standards of Construction for New Existing Nursing Homes. The issue was related to the lack of exam rooms on units. This affected three (Units one, two, and three) of four resident 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:

On 10/25/10 at approximately 2:28 p.m., the third floor room labeled "EXAM ROOM" was observed to be in use as a staff lounge. In an interview at this time, the Environmental Services Supervisor said that it had been used as such for 3-4 years.

On 10/26/10 at approximately 8:52 a.m., the second floor exam room was also observed to be in use as a staff lounge. At 9:12 a.m., the first floor exam room was observed to be in use as a staff lounge.

713-1.18 Mechanical requirements.

(d) Heating and ventilation systems.

(2) Ventilation system details. All air-supply and air-exhaust systems shall be mechanically operated. All fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in Table 8 shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates.

(ii) The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8, below.

TABLE 8 - PRESSURE RELATIONSHIPS AND VENTILATION OF CERTAIN AREAS OF LONG-TERM CARE FACILITIES OTHER THAN CHRONIC DISEASE HOSPITALS.

(Refer to 5310 H 2-29-88)

(iv) Corridors shall not be used to supply air to or exhaust air from any room, except that air from corridors may be used to ventilate bathrooms, toilet rooms, janitors' closets, and small electrical or telephone closets opening directly on corridors.

Based on observations made at the Living Center at Geneva - South during the Recertification Survey, it was determined that the facility did not maintain compliance with Subpart 713-1 Standards of Construction for New Existing Nursing Homes. The issue was related to a lack of mechanical ventilation in a soiled utility room. This affected one (third floor) of three resident sleeping floors, 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:

Observation on 10/25/10 at 1:10 p.m. revealed the third floor South Building dirty utility room is equipped only with a mechanical exhaust of air and lacks a mechanical supply of air. In the past, a waiver has been granted for this condition, with a justification being that there are no problems with odors and infection control. Throughout the survey, surveyors noted significant fecal and urine odors within and surrounding this room, visible debris and grime on the floor, and breached plastic bags of trash and soiled linen deposited directly onto the room floor. For these reasons, the waiver will not be recommended for renewal at this time.

713-1.19 Electrical Requirements.

(g) Nurses' calling system.

(1) General. In general patient areas, each room shall be served by at least one calling station and each bed shall be provided with a call button. Two call buttons serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the patient's door, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems which provide two-way voice communication shall be equipped with an indicating light at each calling station with lights, and remain lighted as long as the voice circuit is operating.

Based on observations made at the Living Center at Geneva - South during the Recertification Survey, it was determined that the facility did not maintain compliance with Subpart 713-1 Standards of Construction for New Existing Nursing Homes. The issue was related to the nurse call system. This affected three (one, two, and three) of three resident sleeping floors, 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:

Observations on 10/26/10 from 12:50 p.m. to 1:15 p.m. revealed the call system did not activate a visible signal (where required) in the following areas: third floor kitchen, supply room across from Room #309 (clean utility), second floor kitchen, clean utility, soiled utility, first floor kitchen, clean utility, and soiled utility. Additionally at this time, the areas mentioned on the first and second floors did contain lights/panels that appeared to be part of the nurse call system, but no signal activated within these rooms when bathroom call strings were pulled in Rooms #206, #106, and #118.

713-2.24

(g) Nurses' calling system.

(1) General. In general resident areas, each room shall be served by at least one calling station and each resident shall be provided with a call device. Two call devices serving adjacent beds may be served by one calling station. Calls shall register with the floor staff and shall activate a visible signal in the corridor at the residents' door, in the clean workroom, in the soiled workroom, and in the nourishment station of the nursing unit. In multi-corridor nursing units, additional visible signals shall be installed at corridor intersections. In rooms containing two or more calling stations, indicating lights shall be provided at each station. Nurses' calling systems which provide two-way voice communication shall be equipped with an indicating light at each calling station with lights, and remain lighted as long as the voice circuit is operating.

Based on observations made during the recertification survey at the Living Center at Geneva - North during the Recertification Survey, it was determined that the facility did not maintain compliance with Subpart 713-2, Standards of Construction for New Nursing Homes. The issue was related to the nurse call system. This affected two (one and two) of two resident sleeping floors, 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:

Observations on 10/26/10 from 12:30 p.m. to 12:48 p.m. revealed the call system did not activate a visible signal in the following areas: first floor Clean Utility room next to Room #129, first floor Nourishment room within the dining room, second floor clean utility room next to Room #229, and second floor nourishment room within the dining room.

Based on staff interviews and record reviews, it was determined that for one of four residents reviewed for injuries of unknown origin, the facility did not thoroughly investigate bruises of unknown origin to rule out resident abuse, neglect, or mistreatment. This affected Resident #103, and resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #103 has diagnoses including dementia.

An observation of a bed bath on 10/26/10 at 10:00 a.m., revealed that the resident had long and thin scabbed areas on the tops of both feet and two other scabbed areas on the left knee. When interviewed at this time, Certified Nursing Assistant (CNA) #1 and CNA #2 both reported that they did not know why the resident had these scabbed areas. They said the resident needs the assistance of two caregivers to get out of bed with the mechanical lift. Also, he does not walk or move without assistance.

Measurements of the scabbed areas taken during a joint observation on 10/27/10 at 2:10 p.m. with the Licensed Practical Nurse (LPN), were as follows: the scab on the top of the left foot was 0.8 x 0.5 centimeters (cm), the top of the right foot was 2 cm in diameter with an open area that measured 0.5 cm x 0.3 cm, and the left knee scab was 1.7 cm long x 0.2 cm wide with a second scabbed area directly beneath measuring 0.3 cm x 0.3 cm.

When interviewed on 10/27/10 at 2:10 p.m., the LPN stated that CNAs are to report any injuries of unknown origin. An Incident and Accident report (I&A) is then started to attempt to determine the cause of the injury of unknown origin. The LPN stated that she was not aware that the resident's feet and left knee were scabbed and confirmed that no I/As had been initiated to review.

When interviewed on 10/27/10 at 2:10 p.m., the Registered Nurse assisting to manage the floor, stated that she did not know that the resident's feet and left knee were scabbed.

The medical record lacked documented evidence that the resident's scabbed areas were reported, assessed, or investigated.

[10 NYCRR 415.4(b)(3)]

Based on observations, staff interviews, and record reviews, it was determined that for 1 of 38 residents reviewed for care plan implementation, the facility did not provide services in accordance with the written plan of care by qualified persons. Specifically, Resident #102's heels were not elevated, and booties were not applied according to the written plan of care. This resulted in no actual harm with the potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

Resident #102 has diagnoses including dementia and pressure ulcers. The Resident Comprehensive Care Flow Sheet, dated 9/30/10, directs staff to place a pillow between the knees, to keep heel pillows on at all times while in bed, and to float heels off all surfaces at all times. The current resident care plan for pressure ulcer prevention includes keeping heels elevated off all surfaces at all times and to apply heel protectors at all times. The physician orders, signed 10/26/10, included to keep heels pressure free at all times, preferably with soft pillow under the lower leg.

Observations made of the resident on 10/25/10 include the following:

1. At 9:15 a.m., the resident's heels were resting directly on the mattress and were not protected with heel protectors or a pillow under the heels.

2. At 11:25 a.m., the resident was lying on her left side. She was wearing blue socks on her feet and her heels rested directly on the mattress. After care was provided, the resident was transferred out of bed to a Geri chair where her heels rested directly on the Geri chair leg rest.

3. From 12:00 p.m. to 1:00 p.m., the resident's feet rested directly on the Geri chair leg rest.

4. At 1:20 p.m., the resident was in her room in the Geri chair with her heels directly touching the Geri chair leg rest.

Observations made of the resident on 10/26/10 include the following:

1. At 7:35 a.m., the resident's feet rested directly on the Geri chair leg rest.

2. At 9:51 a.m., the resident was positioned at 90 degrees in bed, her heels rested directly on the mattress.

3. At 11:00 a.m., there were no booties stored on the linen cart.

4. At 11:10 a.m., the Licensed Practical Nurse said she was not aware of any dark areas on the resident's heels.

5. At 11:40 a.m., the acting Nurse Manager (NM) and two surveyors observed the resident's heels resting directly on the mattress of the bed. The acting NM removed the resident's socks exposing reddened heels. There was a dark brown spot on left heel, and the skin in this area was not blanchable. The skin on the right heel was a lighter red and was blanchable.

6. At 12:50 p.m., the resident was reclined in the Geri chair in the dining room. She was wearing a plaid bootie on her left foot and green slipper socks. When interviewed at this time, the Certified Nursing Assistant stated that she found the bootie in the clean utility room.

7. At 3:00 p.m., the Director of Nursing stated that the resident had a history of hard callusing of the heel, and the current area on the heel was not new. She said that the care plan includes that the resident wear booties on her feet and is to have the heels elevated at all times.

On 10/27/10 at 8:15 a.m., the resident was observed sitting up in a Geri chair wearing two blue booties on her feet. Two red pillows were positioned under her calves, raising her heels off of the surface of the mattress.

[10 NYCRR 415.11(c)(3)(ii)]

Based on observations, record review, and staff interviews, it was determined that for 2 of 25 residents reviewed for professional standards of quality, the facility did not provide service in accordance with professional standards of quality. The issues involved laboratory (lab) work that was not addressed in a timely manner (Resident #111) and physician orders that were not followed prior to medication administration (Resident #112). This resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy, and is evidenced by the following:

1. Resident #111 has diagnoses of hypothyroidism. According to the current physician orders, the resident receives Levothyroxine (thyroid medication) 88 micrograms daily. The 6/28/10 thyroid stimulating hormone (TSH) lab results were high at 4.65 micro units/milliliter(uiu/ml), normal = 0.27- 4.20 uiu/ml. A physician order, dated 8/10/10, included to check a TSH level with next lab draw. The 10/6/10 physician visit note revealed that the thyroid level had not been completed and would be reordered. Record review on 10/27/10 revealed lack of evidence that a current TSH level had been completed.

When interviewed on 10/27/10 at 3:00 p.m., the physician stated that he reviews lab results in his office and must have missed reviewing the results for this test. The physician wrote another order for the TSH level that day.

During an interview on 10/27/10 at 3:35 p.m., the Director of Nursing stated that each unit has a book where the labs are written and when they are drawn, are signed off by the lab technician. The unit secretary or nurses are responsible to go into the Meditech system, a computerized system that contains all laboratory results, to ensure that the lab work has been completed, to identify any abnormal levels, and to report abnormal lab levels to the physician.

When discussing the TSH level on 10/28/10 at 11:30 p.m., the Nurse Manager (NM) stated that she would check the Meditech system for the lab results. At 1:30 p.m., the NM provided printed results of the 8/11/10 TSH that was 11.34 (high). At this time, the NM stated that they rely on the physician to review the results of lab tests.

2. Resident #112 has diagnoses of hypertension. The October 2010 physician orders and Medication Administration Record (MAR) include to give Metoprolol (high blood pressure medication) 12.5 milligrams (mg) every 12 hours, hold for systolic blood pressure < (less than) 100 and heart rate (pulse) <60. There were no heart rates recorded on the September and October 2010 Medication Administration Sheets.

During the medication pass observation on 10/26/10 at 10:50 a.m., the LPN did not take the resident's blood pressure or pulse before giving the resident Metoprolol. In an interview that day at 11:03 a.m., the LPN stated that she had not taken the resident's blood pressure before giving the Metoprolol. She added that the resident's blood pressure is pretty regular, and then proceeded to take the resident's blood pressure.

Review of the October MAR on 10/27/10 at 4:10 p.m. revealed that the 10/26/10 blood pressure taken at 11:03 a.m. was not recorded.

When interviewed on 10/27/10 at 4:15 p.m, the LPN stated that she did not take the heart rate on 10/26/10 at 10:50 a.m. The LPN reported that after the medication pass observation on 10/26/10, she contacted the physician for a time change for the Metoprolol. She then re-wrote the Metoprolol order on the October MAR to separate the blood pressure and heart rates. The LPN said that she had not found documentation that heart rates were done during the months of September or October 2010.

[10 NYCRR 415.11(c)(3)(i)]

Based on document review and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not have an approved fire watch plan to implement in the event that the automatic sprinkler system is out of service for more than 4 hours in a 24-hour period. This affected the entire building (four of four resident units and the administrative wing), resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

On 10/27/10 between the hours of 8:45 a.m. and 11:45 a.m., the facility's fire and emergency plans were reviewed. This review revealed that there was not an approved fire watch plan that would be implemented in the event that the automatic sprinkler system is out of service for more than 4 hours. In an interview with the Administrator at approximately 12:45 p.m., he indicated that he could not provide the fire watch plan at this time. It is noted that no fire watch plan was provided by the facility.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 9.7.6.1; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 7-7.6]

Based on document review and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not properly conduct fire drills nor prepare staff to respond to a fire situation. This affected four (Units 1, 2, 3, and SNU) of four resident units, and resulted in no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread. The findings are:

1. On 10/26/10, fire drill reports were reviewed from the previous twelve months. As a result, fire drills were identified whereby the fire alarm was not sounded. Some of these drills were conducted outside the time-frame established by NFPA 101. These included the drills held on the following dates and at the following times:

a) 10/15/10 at 8:42 p.m.,
b) 8/24/10 at 6:13 p.m.,
c) 7/7/10 at 5:10 p.m.,
d) 1/29/10 at 8:20 p.m.,
e) 12/9/09 at 4:17 p.m.,
f) 10/2/09 at 8:00 p.m.

During an interview at approximately 3:00 p.m., the Environmental Services Supervisor confirmed that the fire alarm was not sounded during these drills.

2. On 10/27/10, between the hours of 10:30 a.m. and 11:30 a.m., selected facility staff members were interviewed to determine their familiarity with fire procedures established by the facility. When asked what is signified by a red/orange tag hanging from a door handle, 7 of 12 staff members gave answers that were not consistent with the facility's fire plan. Responses included that it signifies the fire is inside, that a fire is not inside, that a resident is inside, and that it is safe inside. It is noted that the facility's fire plan indicates that a red/orange tag hanging from a door handle means that the room has been evacuated.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.7.1.2, 19.7.1.3; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-7.1.2, 13-7.1.3]

Based on observations conducted during the Life Safety Code Survey, it was determined that the facility did not protect structural components from fire. Issues included steel I-beams and web trusses observed above ceiling tiles that were not protected from fire. THIS IS A REPEAT DEFICIENCY FROM THE LIFE SAFETY CODE SURVEY OF 10/22/09. This affected three (Units 1, 2, and 3) of four resident units, resulting in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. On 10/26/10 from approximately 12:45 p.m. to 2:15 p.m., observations above ceiling tiles revealed :

a) On the third floor between the elevator and the central stairwell, uncoated steel I-beams were present (an approximately 7-foot length along the stairwell and an approximately 10-foot length at the exterior wall).

b) On the second floor in the exam room, an approximately 18-foot length of uncoated steel I-beam and web trusses were present.

c) On the first floor in Room #119, an approximately 12-foot length of uncoated steel I-beam and web trusses were present.

2. The building construction type has been previously determined to be Type II (222) through documents provided by the facility. The 1999 edition of NFPA 220, Standard on Types of Building Construction, states that for this construction type, structural members including beams, girders, trusses, and arches are required to be of approved noncombustible or limited combustible materials and shall have a fire resistance rating of not less than two hours. The steel beams and trusses were exposed above the ceiling tiles, and the facility did not provide any documentation to show that fire protection was provided by a rated ceiling system.

3. The facility has secured the services of a Fire Protection Engineer to complete a "Fire Safety Evaluation System" (FSES) report. This report has been submitted to this office for review and evaluation. If the report is found to be valid, the facility will be deemed to be compliant on this deficient issue based on this equivalency system.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.1.6.2; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-1.6.2; NFPA 220 1999ed. 3-1]

Based on observations made during the Life Safety Code Survey, it was determined that the facility did not properly maintain corridor doors. The issue was related to corridor doors to resident rooms that had undercuts (distance between the bottom of the door and the floor) exceeding 1-inch. This affected one of two resident sleeping floors, 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:

Observations in the South Building on 10/26/10 from 11:07 a.m. to 11:17 a.m. revealed the following corridor doors had undercuts exceeding 1-inch: Rooms #105, #110, #112, and #118. When in the closed position, the surveyor measured the undercuts to be between 1 1/8-inch and 1 3/4-inch. The 2000 edition of NFPA 101, Life Safety Code requires undercuts of corridor doors to be 1-inch or less.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.3.6.3.1; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-3.6.3.1]

Based on observations and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not provide decorations that were flame-retardant. The issue was related to Halloween decorations that were displayed in various areas of the facility. This affected portions of three (Units 1, 3, and SNU) of four resident units as well as the Administrative wing. This resulted in a pattern of no actual harm with potential for more than minimal harm that is not immediate jeopardy. The findings are:

1. On 10/25/10 at approximately 1:20 p.m. in the Special Needs Unit, a large, white ghost decoration comprised of fabric sheets was observed. This decoration was stretched across the upper wall/ceiling area across from the nurses' station and was approximately 12 feet x 3 feet. In an interview with the Environmental Services Supervisor (ESS) at this time, he said that this decoration had not been treated to render it flame-retardant.

2. On 10/25/10 at approximately 2:15 p.m. on Unit 3, a plastic poster-like decoration was affixed to the bathing suite door. This decoration was approximately 2.5 feet x 3.5 feet.

3. On 10/26/10 at approximately 9:30 a.m. on Unit 1, a fabric artificial spiderweb was stretched across the ceiling near the storage closet. This fabric was approximately 14 feet x 4 feet.

4. On 10/26/10 at approximately 10:30 a.m., a plastic poster-like decoration was affixed to the door of the Activity Director's office. This decoration was approximately 2.5 feet x 6 feet.

5. On 10/26/10 at approximately 10:55 a.m., the cafeteria was observed to have numerous decorations present, including a fabric, illuminated, inflated decoration with a bat emerging from a pumpkin.

6. On 10/26/10 at approximately 11:00 a.m., a fabric quilt was observed to be hanging from a wall in the library. This quilt was approximately 5 feet x 8 feet. In an interview with the ESS at this time, he said that the quilt had not been treated to render it flame-retardant.

No documentation was provided by the facility to show that any of these decorations were flame-retardant.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.7.5.4; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 13-7.5.4]

Based on observations, document review, and staff interview conducted during the Life Safety Code Survey, it was determined that the facility did not properly maintain the automatic sprinkler system. The issues were related to obstructions to sprinkler heads and to fire hydrants not being maintained. This affected the entire building, resulting in no actual harm with potential for more than minimal harm that is not immediate jeopardy and is widespread The findings are:

1. On 10/25/10 at approximately 1:05 p.m., the sprinkler heads in the bathing suite of the Special Needs Unit were evaluated. At this time, it was observed that a trash receptacle was present in the toilet alcove of this suite. The sprinkler head protecting the toilet alcove was located outside the toilet alcove. The toilet alcove was separated from the suite by a shower curtain. This shower curtain did not have a mesh or open top but, rather, was solid from top to bottom and was hung 1 to 2 inches from the ceiling.

2. In the Administrative wing, the men's and women's rest rooms had a single sprinkler head each. Within 6 inches from each sprinkler head, a light fixture was installed. The vertical distance between the bottom of the light fixture and each sprinkler head was approximately 2 inches.

These conditions created obstructions to the spray pattern for these sprinkler heads.

3. On 10/25/10 at approximately 10:00 a.m., an interview with the Lead Mechanic indicated that private fire hydrants are located on the premises. When physical plant documents were reviewed, it was determined that four of five hydrants had last been inspected, tested, and maintained in 2008. The 1998 edition of NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, requires fire hydrants to be inspected, tested, and maintained on an annual basis.

[42 CFR 483.70(a)(1); NFPA 101 LSC 2000: 19.7.6, 4.6.12.2; 10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 1997: 1-3.13.2; NFPA 25, 1998 ed. 2-2.1.2, 4-2.2.4, 4-3.2, 4-4.3.1]