Mercy Hospital Skilled Nursing Facility

Based on observation, record review and staff interview, the Consultant Pharmacist did not identify or report drug regimen irregularities to the Attending Physician and the Director of Nursing (DON) as required. Three (Residents #44, 52, 66) of ten residents reviewed for drug regimen reviews had issues involving the lack of Pharmacist identification and reporting of physician's orders that did not include pain parameters and specific indications for the administration of PRN (as needed) pain medications and incomplete medication orders that did not include the dosage and application site for administration. This was a pattern with no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #44 has diagnoses which include cerebral vascular accident (CVA-stroke), hemiplegia (paralysis of one side of body), depression, and opioid (narcotic pain medication derived from opium) dependence. Review of the Minimum Data Set (MDS) dated 6/23/11 revealed the resident is cognitively intact.

Review of Physician's Orders dated 6/1/11 through 8/4/11 revealed orders for the following PRN (as needed) medications:

- Oxycodone (narcotic pain medication) 10 milligrams (mg) by mouth every 3 hours as needed for pain
- Acetaminophen (Tylenol) 650 mg (rectal suppository or by mouth) every 4 hours as needed for pain or temperature over 101 degrees. The 8/4/11 Physician's Orders for the PRN pain medication orders did not specify the level of pain that each medication should be administered for.

Review of the Pain Management Tracking Forms dated 6/11 and 7/11 revealed documentation that the resident had back pain level indicators between 5 and 10 (on a pain scale from 0 to 10) and received either the PRN Acetaminophen or the PRN Oxycodone to manage the pain. Additional review revealed the resident was given Oxycodone or Acetaminophen to manage the same levels of pain.

Review of a Medication Regimen Review Progress Note Sheet dated 6/10/10 to 7/15/11 revealed the Consultant Pharmacist reviewed Resident #44's medication regimen on 4/19/11, 5/10/11, 6/14/11, and 7/15/11 and did not report the irregularity in the PRN Oxycodone and Acetaminophen orders to the Physician or the Director of Nursing (DON).

Interview with the Registered Pharmacist on 8/15/11 at 12:30 PM revealed the Physician's Order for pain medications should specify the level of pain that each medication is for, "It should be spelled out in the order".

2. Resident #66 has diagnoses including diabetes mellitus, dementia, Parkinson's disease, peripheral vascular disease (poor circulation of the lower extremities) and pain. Review of the Minimum Data Set (MDS) dated 7/20/11 revealed the resident has severe cognitive impairment and short and long term memory problems. Further review of the MDS revealed the resident is on a scheduled pain medication regimen.

Review of Physician's Orders dated 3/18/11 through 7/21/11 revealed an order for Lidocaine (local anesthetic medication) ointment 5 percent (%), apply topically to affected area with a 4 x 4 (4 inch by 4 inch gauze dressing) on in AM off at bedtime (hs). The Physician's Order did not specify the amount of Lidocaine to apply or the body area to apply the ointment.

Review of Medication Records dated 3/1/11 through 8/11/11 revealed documentation that the Lidocaine ointment 5 % was applied "topically to affected area" daily with a 4 x 4, on in the AM and off at bedtime.

Review of a Medication Regimen Review sheet dated 1/31/10 to 7/18/11 revealed the Pharmacist Consultant did not identify that the Physician's Orders for Lidocaine did not include the site for administration or the dose of the Lidocaine ointment.

Interview with the Licensed Practical Nurse (LPN) Medication Nurse (MN) on 8/11/11 at 2:00 PM revealed she applied the Lidocaine ointment with a gloved hand and did not use a 4 x 4. When the LPN Medication Nurse was asked how much Lidocaine she applied, the LPN responded that she applied it with a gloved hand "like Ben Gay" but she "only put a little on and doesn't gob it on like the other nurses".

Interview with the 3:00 PM to 11:00 PM shift LPN Medication Nurse on 8/11/11 at 4:30 PM revealed that she usually works on the unit so she knows to wash off the resident's back in the evening and doesn't know if any of the agency nurses would know.

Review of a facility policy entitled Ordering and Receiving Medications from the Dispensing Pharmacy dated 5/1/09 revealed medication orders are to include the medication name and strength and directions for use.

Review of a facility policy entitled Daily Verification of all Physician Orders Each Resident/Patient is to Receive, dated 11/09 revealed that the night shift nurse is responsible to review the orders.

Interview with the Pharmacist Consultant on 8/11/11 at 11:20 PM revealed he missed the incomplete Physician's Order and should have identified that it was missing the amount of Lidocaine to administer and the location of where it is to be applied.

3. Resident #52 has diagnoses of arthritis, bipolar disorder, hypertension, and renal failure. The Minimum Data Set (MDS) dated 6/2/11 revealed the resident is cognitively intact.

Review of Physician's Orders dated 12/7/10, 2/11/11, 4/12/11 and 6/14/11 revealed an order to dissolve one packet of MiraLax (laxative) in 240 cubic centimeters (cc) of liquid and administer once daily.

Observation on 8/11/11 at 9:50 AM revealed the Licensed Practical Nurse (LPN) Medication Nurse was observed to pour MiraLax powder into the cap of the bottle and then mix it in a glass of water and administer it to the resident.

When interviewed on 8/11/11 at 9:45 AM, the LPN Medication Nurse (MN) stated she called the pharmacy and they told her one MiraLax packet equals one capful so that is what she gives. The LPN Medication Nurse explained that the MiraLax is not provided by the pharmacy because it is too expensive and it is purchased by the facility. The LPN stated that the Medication Administration Record (MAR) should document the MiraLax dosage; she will change it on the MAR and notify the pharmacy.

During an interview on 8/11/11 at 10:29 AM, the Unit Secretary explained that when a resident is admitted to the facility, the orders are faxed to the pharmacy and the pharmacy prints a monthly order sheet. Verbal/telephone orders are faxed to pharmacy and they are added to the monthly orders.

When interviewed on 8/11/11 at 11:02 AM, the Consultant Pharmacist stated he knows that one packet of MiraLax Plus is equal to one capful from the bulk container but the nurse might not know that. After review of Resident #52's MAR dated 8/11, the Pharmacist stated that the MiraLax order should have a dosage. The Pharmacist stated that he expects the nurse to follow the 5 rights (right patient, medication, dose, route, and time) when administering a medication and that includes the right dosage. The Pharmacist explained that facilities are switching from packets to bulk MiraLax because of cost; some still use packets and he was not sure what this facility is using. The Pharmacist was observed to instruct the Medication LPN to get an order clarification for the MiraLax dosage.

When interviewed on 8/11/11 at 12:56 AM, the LPN Medication Nurse stated there are two other residents who are receiving bulk MiraLax, that have a MiraLax packet order.

415.18(c)(2)

Based on observation, record review and staff interview the facility did not maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. Two (Residents #18, 66) of 3 resident records reviewed for pressure ulcers had issues involving the incorrect documentation of the location of an open area (Resident #66) and the lack of accurate, complete documentation of pressure ulcer assessments, including wound measurements, in the medical records (Resident #18). There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Resident #66 has diagnoses including diabetes mellitus, dementia, Parkinson's disease, peripheral vascular disease (poor circulation of the lower extremities) and pain. Review of the Minimum Data Set (MDS) dated 7/20/11 revealed the resident has severe cognitive impairment and short and long term memory problems. Further review of the MDS revealed the resident has a lower limb prosthesis and is on a scheduled pain medication regimen.

Review of the current Resident Care Plan last revised 7/27/11 revealed the resident has a history of a left below the knee amputation and an open area on the right lateral (situated on the outer side) foot.

Interview with the Director of Nursing (DON) on 8/9/11 at approximately 10:00 AM revealed that Registered Nurse (RN) Supervisor #1 was the facility Wound/Skin Nurse.

Review of Wound Skin Notes dated 4/5/11 through 8/1/11 revealed the resident had a dark intact blister located on the lateral aspect of his right foot on 4/5/11. Additional review of the Wound Skin Notes revealed the following:

- On 4/13/11, RN Supervisor #1 documented that the resident had a black area on the lateral aspect of the right foot measuring 2 centimeter (cm) x 1 cm.
- On 6/7/11, RN Supervisor #1 documented there was an open area on the resident's right lateral heel that increased in size.
- On 6/14/11, RN Supervisor #1 documented that the open area on the left lateral heel measured 1 cm x 1 cm.

Further review of the Wound Skin Notes revealed that RN Supervisor #1 (Wound/Skin Nurse) incorrectly identified that the open area was located on the resident's left foot from 6/14/11 through 7/17/11.

Observation of a wound treatment on 8/11/11 at 11:00 AM revealed the resident was sitting in a lounge chair with his right foot resting on a towel. The Licensed Practical Nurse (LPN) was observed to provide the wound treatment to an open area located on the lateral aspect of the resident's right foot. The resident was observed to have a below the knee amputation of the left leg.

Interview with RN Supervisor #1 on 8/12/11 at approximately 2:00 PM revealed she incorrectly documented that the open area was located on the resident's left lateral heel from 6/14/11 through 7/17/11. The RN Supervisor confirmed that the open area was on the resident's right lateral heel.

During an interview on 8/12/11 at approximately 5:00 PM, the DON stated that RN Supervisor #1 gets her right and left mixed up "all of the time".

2. Resident #18 has diagnoses including multiple sclerosis, spinal stenosis (narrowing of one or more areas in the spine), peripheral neuropathy (poor circulation of the lower extremities), paralysis, and quadriplegia (paralysis of all four limbs). Review of the Minimum Data Set (MDS) dated 6/3/11 revealed the resident is independent in daily decision making and has intact memory. Further review of the MDS revealed the resident has a Stage 4 pressure ulcer (sore).

Review of a Braden Scale, an assessment tool used to determine risk for developing a pressure ulcer, dated 6/21/11 revealed the resident had a score of 14, indicating high risk.

Review of the Resident Care Plan dated 6/16/11 revealed the resident was identified at risk for further skin breakdown related to a Stage 4 pressure ulcer. Care Plan approaches included completing weekly skin assessments of the current areas, and monitoring size and stage by the Skin Care Team.

Interview with the Administrator on 8/11/11 at approximately 10:00 AM revealed the Registered Nurse (RN) Supervisor #1 is the facility's Wound/Skin Nurse.

Review of a Wound Skin Note dated 2/7/11 revealed the resident had a Stage 4 pressure ulcer on the Ischial Tuberosity ("sitting bone" in the buttocks-exact location not identified) measuring 6 centimeter (cm) by (x) 4 cm. Additional review revealed the depth of the pressure ulcer measured 3.2 cm at 12:00 (identification of location using the face of a clock), 0.7 cm at 3:00, 1.4 cm at 6:00, and 2.5 cm at 9:00. A Wound Skin Note dated 7/17/11 documented the pressure ulcer "persists".

Further review of the Wound Skin Notes revealed there was no documentation that the Stage 4 pressure ulcer was assessed/measured as follows:

- For 13 days from 2/18/11 to 3/3/11
- For 12 days from 4/12/11 to 4/24/11
- For 19 days from 4/24/11 to 5/13/11
- For 10 days from 7/7/11 to 7/17/11
- From 7/18/11 to 8/12/11

Review of the Wound Skin Notes and Nursing Notes dated 2/8/11 through 8/12/11 revealed there was no documented evidence that the Stage 4 pressure ulcer located on the resident's left Ischial Tuberosity was consistently measured and assessed weekly by an RN.

Observation on 8/12/11 at approximately 11:00 AM revealed the resident had a healing Stage 4 pressure ulcer on the left Ischial Tuberosity.

During an interview on 8/12/11 at approximately 3:00 PM, RN Supervisor #1 stated she assessed and measured the pressure ulcer on 7/17/11 and then went out on medical leave. RN Supervisor #1 explained that while she was gone from the facility, RN Supervisor #2 was supposed to measure and assess the resident's pressure ulcer. During the interview, RN Supervisor #1 was observed to speak to RN Supervisor #2 on the telephone and RN Supervisor #2 stated she did not measure the size of the pressure ulcer during RN Supervisor #1's absence. RN Supervisor #1 stated she measured the pressure ulcer on 8/8/11 but she has not documented the assessment or measurements in the resident's medical record. RN Supervisor #1 stated she did "jot down" the pressure ulcer measurements from 8/8/11 and she provided an empty wrapper from an Allevyn dressing (absorbent wound dressing) with the following handwritten notations:

- The initials of the resident.
- "6-12, 3.5"
- "9-3, 3.7"
- "Depth 12, 1.8"
- "3, 0"
- "6, 0.5"
- "9, 1"

Observation of the Allevyn package and review of Nursing Progress Notes dated 8/8/11 through 8/12/11 revealed there was no written information regarding the appearance, location or the stage of the pressure ulcer or of the unit of measurements used.

During interviews on 8/12/11 at approximately 5:00 PM and 8/15/11 at approximately 7:45 AM, the Director of Nursing (DON) stated that RN Supervisor #2 did not do what she was supposed to - she did not measure Resident #18's pressure ulcer during RN Supervisor absence. The DON stated that she measured the resident's pressure sore on 7/25/11 and 8/1/11, but there is so much to do. The DON stated that she did not chart the measurements in the computer and had the measurements on 2 different pieces of paper in her office.

During the interview, the DON explained that the corporation for the facility wants pressure ulcer assessments including measurements, documented on "Wound Skin Detail Report" sheets in the computer and this documentation was to start in 3/11. The DON stated the nurses have not consistently documented the pressure ulcer information on this form because "they forget about the form or don't always have the time to enter the information". A copy of the Wound Skin Detail Report for Resident #18 was requested. The DON provided a copy and stated that she just entered the documentation for 7/25/11 and 8/1/11 prior to providing the requested copy to the surveyor. The DON stated she was just notified on Friday 8/12/11 that RN Supervisor #2 did not assess and measure the resident's pressure ulcer while RN Supervisor #1 was out on leave. The DON stated she had written the 7/25/11 and 8/1/11 pressure ulcer measurements on her own papers and she did not enter the documentation into the Wound Skin Detail Report until after the surveyor had requested the documentation. The DON stated she just realized there were "gaps in the documentation" and cannot state that the Wound/Skin assessments were done weekly.

During an interview on 8/15/11 at approximately 9:00 AM, the Administrator stated that the facility did have an issue with the documentation and it will be corrected.

415.22(a)(1-3)

Based on record review and staff and resident interview, the facility did not ensure that each resident's drug regimen is free from unnecessary drugs. One (Resident #44) of 10 residents reviewed for pain management had orders for multiple PRN (as needed) pain medications without documented parameters and specific indications for administration. Narcotic and non-narcotic pain medications were administered for the same pain levels. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident #44 has diagnoses which include cerebral vascular accident (CVA-stroke), hemiplegia (paralysis on one side of body), depression, and opioid (narcotic pain medication derived from opium) dependence. Review of the Minimum Data Set (MDS) dated 6/23/11 revealed the resident is cognitively intact.

Review of the Resident Care Plan dated 8/10/11 revealed the resident has chronic pain and has an addiction to pain medication with an approach to administer analgesics (pain killing medications) as ordered.

Review of Physician's Order's dated 8/4/11 revealed orders for scheduled pain medications included the following:

- Methadone (synthetic narcotic pain medication) 25 milligrams (mg) by mouth three times daily at 9:00 AM, 2:00 PM, and 8:00 PM
- Oxycodone (narcotic pain medication) 10 mg by mouth daily at 9:00 PM
- Tramadol (narcotic - like pain reliever used to treat moderate to severe pain) 50 mg by mouth daily at 1:00 AM
- Acetaminophen (Tylenol) 650 mg by mouth at 12:00 AM and 4:00 AM

Additional review of the 8/4/11 Physician's orders revealed orders for the following PRN (as needed) medications:

- Oxycodone 10 mg by mouth every 3 hours as needed for pain
- Acetaminophen 650 mg (rectal suppository or by mouth) every 4 hours as needed for pain or temperature over 101 degrees.

The 8/4/11 Physician's Orders for the PRN pain medication orders did not specify the level of pain that each medication should be administered for.

Review of Pain Management Tracking Forms dated 7/11 and 8/11 revealed documentation that the resident had back pain level indicators between 5 and 10 (on a pain scale from 0 to 10) and received either the PRN Acetaminophen or the PRN Oxycodone to manage the pain. The resident was given Oxycodone or Acetaminophen to manage the same levels of pain.

Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 8/15/11 at 8:50 AM revealed the facility does do not have a policy regarding the administration of PRN pain medications including how to determine when to administer pain medications for a specific pain level.

Interview with the Licensed Practical Nurse (LPN) Medication Nurse on 8/15/11 at 9:15 AM revealed the facility does not have a policy for giving Acetaminophen or Oxycodone based on a pain scale. The LPN Medication Nurse stated that she does ask the resident what level of pain she has. The LPN explained that if the resident "is grimacing I give her the Oxycodone, otherwise I give her Acetaminophen".

During an interview on 8/15/11 at 9:10 AM, the resident stated that she doesn't ask the nurse for Tylenol or the Oxycodone, they just give her a pill.

Interview with the Registered Pharmacist on 8/15/11 at 12:30 PM revealed the Physician's Order for pain medications should specify the level of pain that each medication is for, "It should be spelled out in the order".

415.12(l)(1)

Based on observation, record review, and staff and resident interviews the facility did not ensure that a resident having pressure sores receives necessary treatment and services to promote healing, prevent infection and prevent new sores from developing. One (Resident #18) of three residents reviewed for pressure sores had issues involving the lack of weekly assessments, of a Stage 4 pressure sore, including measurement of size, by a Professional Registered Nurse. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The finding is:

1. Resident # 18 has diagnoses including multiple sclerosis, spinal stenosis (narrowing of one or more areas in the spine) peripheral neuropathy (poor circulation of the lower extremities), and quadriplegia (paralysis of all four limbs). Review of the Minimum Data Set (MDS) dated 6/3/11 revealed the resident is independent in daily decision making and has intact memory. Additional review of the MDS revealed the resident had a Stage 4 pressure ulcer (sore).

Review of the Resident Care Plan dated 6/16/11 revealed the resident was identified at risk for further skin breakdown related to a Stage 4 pressure ulcer. Care Plan approaches included completing weekly skin assessments of the current areas, and monitoring size and stage by the Skin Care Team.

Review of a Braden Scale, an assessment tool used to determine risk for developing a pressure ulcer, dated 6/21/11 revealed the resident had a score of 14, indicating high risk.

Interview with the Administrator on 8/11/11 at approximately 10:00 AM revealed the Registered Nurse (RN #1) Supervisor is the facility's Wound/Skin Nurse.

Review of a Wound Skin Note dated 2/7/11 revealed the resident had a Stage 4 pressure ulcer on the Ischial Tuberosity ("sitting bone" in the buttocks-exact location not identified) measuring 6 centimeter (cm) by (x) 4 cm. Additional review revealed the depth of the pressure ulcer measured 3.2 cm at 12:00 (identification of location using the face of a clock), 0.7 cm at 3:00, 1.4 cm at 6:00, and 2.5 cm at 9:00. A Wound Skin Note dated 7/17/11 documented the pressure ulcer "persists".

Further review of the Wound Skin Notes revealed there was no documentation that the Stage 4 pressure ulcer was assessed/measured as follows:

- For 13 days from 2/18/11 to 3/3/11
- For 12 days from 4/12/11 to 4/24/11
- For 19 days from 4/24/11 to 5/13/11
- For 10 days from 7/7/11 to 7/17/11
- From 7/18/11 to 8/12/11

Review of the Wound Skin Notes and Nursing Notes dated 2/18/11 through 8/12/11 revealed no documented evidence that the Stage 4 pressure ulcer located on the resident's left Ischial Tuberosity was consistently measured and assessed weekly by an RN.

Observation on 8/12/11 at approximately 11:00 AM revealed the resident had a healing Stage 4 pressure ulcer on the left Ischial Tuberosity.

During an interview on 8/12/11 at approximately 3:00 PM, RN Supervisor #1 stated she assessed and measured the pressure ulcer on 7/17/11 and then went out on medical leave. RN Supervisor #1 explained that while she was gone from the facility, RN Supervisor #2 was supposed to measure and assess the resident's pressure ulcer. During the interview, RN Supervisor #1 was observed to speak to RN Supervisor #2 on the telephone and RN Supervisor #2 stated that she did not measure the size of the pressure ulcer during RN Supervisor #1's absence. RN Supervisor #1 stated she measured the pressure ulcer on 8/8/11 but she has not documented the assessment or measurements in the resident's medical record. RN Supervisor #1 stated she did "jot down" the pressure ulcer measurements from 8/8/11 and she provided an empty wrapper from an Allevyn dressing (absorbent wound dressing) with the following handwritten notations:

- The initials of the resident.
- "6-12, 3.5"
- "9-3, 3.7"
- "Depth 12, 1.8"
- "3, 0"
- "6, 0.5"
- "9, 1"

Observation of the Allevyn package and review of Nursing Progress Notes dated 8/8/11 through 8/12/11 revealed there was no written information regarding the appearance, location or the stage of the pressure ulcer; or of the unit of measurements used.

During interviews on 8/12/11 at approximately 5:00 PM and 8/15/11 at approximately 7:45 AM, the Director of Nursing (DON) stated that RN Supervisor #2 did not do what she was supposed to - she did not measure Resident #18's pressure ulcer during RN Supervisor absence. The DON stated that she measured the resident's pressure sore on 7/25/11 and 8/1/11 but there is so much to do. The DON stated she did not chart the measurements in the computer and had the measurements on 2 different pieces of paper in her office.

During the interview, the DON explained that the corporation for the facility wants pressure ulcer assessments including measurements, documented on "Wound Skin Detail Report" sheets in the computer and this documentation was to start in 3/11. The DON stated the nurses have not consistently documented the pressure ulcer information on this form because "they forget about the form or don't always have the time to enter the information". A copy of the Wound Skin Detail Report for Resident #18 was requested. The DON provided a copy and stated that she just entered the documentation for 7/25/11 and 8/1/11, prior to providing the requested copy to the surveyor. The DON stated she just was notified on Friday 8/12/11 that RN Supervisor #2 did not assess and measure the resident's pressure ulcer while RN Supervisor #1 was out on leave. The DON stated she had written the 7/25/11 and 8/1/11 pressure ulcer measurements on her own papers and she did not enter the documentation into the Wound Skin Detail Report until after the surveyor requested the documentation. The DON stated she just realized there were "gaps in the documentation" and cannot state that the Wound/Skin assessments were done weekly.

Interview with the resident on 8/15/11 at approximately 8:00 AM revealed the nurses do the treatment as needed but she didn't think that they remember to measure weekly.

Interview with the DON and Administrator on 8/15/11 at approximately 11:00 AM revealed there was no additional information available.

415.12(c)(2)

Based on observation and staff interview, oxygen storage was not properly maintained. This affected one (Unit 6) of four resident units and one of one Ground Floor Oxygen Storage room. This was a pattern with no actual harm with the potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 8/9/11 at approximately 9:16 AM revealed that there was an E sized oxygen cylinder attached to a wheelchair located in the Bathing Spa, room #629 on Unit 6. Also at this time observation revealed that a duplex electrical outlet and an electrical light switch were installed less than five feet from the floor's surface in the room. Further observation at this time revealed that this room lacked signage that oxygen was being stored within the room.

Interview with the Registered Nurse (RN) Resident Care Coordinator (RCC) on 8/9/11 at approximately 9:49 AM revealed that the E sized oxygen cylinder attached to a wheelchair located in the Bathing Spa, room #629 had probably been there since late afternoon on 8/8/11.

2. Observation on 8/9/11 at approximately 11:39 AM revealed that a duplex electrical outlet and an electrical light switch were installed less than five feet from the floor's surface in the Ground Floor Oxygen Storage room. Also at this time observation revealed that three approximately seven foot tall by four inch long by two inch wide pieces of wood were stored less than five feet from 12 E sized oxygen cylinders that were located within the room.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 1999 NFPA 99: 8.3.1.11.2(c)2, 8.3.1.11.2(f), 8.3.1.11.3

Based on observation and staff interview during a Life Safety Code survey, the facility did not properly construct a building addition. This affected one of one exit access from the Ground floor cafe that leads to the exterior of the building. There was no actual harm with potential for more than minimal harm that is not immediate jeopardy.

The findings are:

1. Observation on 8/10/11 at approximately 10:25 AM revealed an approximate 11 foot tall by 10 foot long by six foot wide wooden structure was observed to be attached to the South East side of the building. Also at this time observation revealed that the structure was comprised of a wooden roof, ceiling, walls, supports and rafters that were not protected from fire. Further observation at this time revealed that this structure enclosed an exit stairway that leads from the Ground Floor Cotroneo Cafe to the exterior of the building and that it was not protected by an automatic sprinkler system. Continued observation at this time revealed a resident was observed in the Cotroneo Cafe. Observation above the ceiling tiles of the Cafe revealed an approximate two inch long by two inch wide open, unsealed penetration around a conduit that ran through the wall that separated the Cafe from the stairway.

Interview with the Administrator on 8/10/11 at approximately 10:36 AM revealed that the Cotroneo Cafe opened in 10/09. This area of the facility was not being used and/or was under construction prior to this time.

Observation on the Ground Floor on 8/10/11 at approximately 1:38 PM revealed that the door that separated the Cotroneo Cafe from the stairway was a non-rated, hollow metal door that would not self-close and latch into its frame. Also at this time a resident was observed in the Cotroneo Cafe. The 2000 edition of NFPA 101, Life Safety Code, requires that building additions conform to the provisions for new construction. Newly constructed buildings, if made from combustible structural supports, must have those structural supports protected from fire.

10 NYCRR 415.29(a)(2), 711.2(a)(1)
none 2000 NFPA 101: 18.1.6.2, 4.6.6