Andrus On Hudson
July 11, 2016 Certification Survey

Standard Health Citations

FF09 483.35(d)(3):FOOD IN FORM TO MEET INDIVIDUAL NEEDS

REGULATION: Each resident receives and the facility provides food prepared in a form designed to meet individual needs.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that food was served in a form designed to meet the needs of 5 of 5 residents residing on the Dementia Unit on the Fifth Floor and reviewed for mechanically altered/consistency diets (Residents #49, #32 and #174, #6 and #8). The findings include: 1. Resident #49 has [DIAGNOSES REDACTED]. According the Quarterly Minimum Data Set (MDS; a resident assessment tool) dated 4/5/16 the resident scored 3 out of 15 on the BIMS (Brief Interview for Mental Status; used to test orientation and memory recall) which suggested that the resident has severe cognitive impairment and required extensive assistance with eating. One of the nutritional goals for the resident, as reflected in the care plan dated 1/13/16, was for the resident to tolerate her diet. The resident's most recent physician's orders [REDACTED]. On 7/6/16 during a lunch meal, the resident was observed eating in one of the dining rooms on the 5th floor. According to the meal ticket that accompanied the resident's tray, she was to be served a Soft to Chew diet as prescribed by the physician. The items served to the resident included a tossed salad consisting of sliced cucumbers with skin and tomato wedges (not thinly cut) and oven-baked garlic bread. The resident was left to feed herself independently. The resident was observed to place a tomato wedge in her mouth, ate the fleshy part and placed the remaining portion of the wedge back on her tray. Additionally, she placed the garlic bread in her mouth and returned it to her tray without biting it. At the time of the above observation, the Registered Dietitian (RD) was present and was asked if the resident was to be served garlic bread. The RD stated that it was not allowed. The menu for the Soft to Chew diet and the printed menu on the resident's meal ticket did not include garlic bread. (The surveyor tasted the bread and it was firm but not hard.) A review of the diet manual revealed that a Soft to Chew diet can be ordered for residents who have difficulty chewing and/or biting some foods. The foods item not allowed included garlic bread and fresh vegetables, excluding fresh tomato slices, lettuce, and coleslaw. 2. Resident #32 has [DIAGNOSES REDACTED]. According to the most recent dental consult dated 8/19/15, the resident has a total of eight lower missing teeth and wears a full upper denture. The most current nutrition care plan dated 3/28/16 revealed that the resident needed a mechanically-altered diet related to dysphasia and dementia. The Quarterly MDS dated [DATE] showed that the resident had severe cognitive impairment and required limited assistance with eating. The most recent physician's orders [REDACTED]. According to the facility's diet manual, this diet promotes self feeding in that most items and certain vegetables are cut into bite-size pieces. In general, the textures are soft with no tough skins; and dry, crispy or stringy foods are omitted. During an evening meal observation on 7/7/16, the resident was served a slice of pizza cut crosswise into three pieces. One of these pieces contained the edge of the crust which was not soft to chew and was intact. The resident was also served a regular marinated vegetable salad consisting of chunks or slices of vegetables. According to the menu for the chopped diet, the pizza and the salad should have been served chopped. (The cheese on the pizza was mozzarella, which is stringy when heated.) The crust of the pizza was tasted by one of the surveyors and it was noted to be soft to chew, excluding the edge which was firm, chewy and not hard. The resident was left unattended to eat food independently. The resident made no attempt to feed himself. A staff member present cut the pizza into small pieces, after surveyor's intervention. 3. Resident #174 has [DIAGNOSES REDACTED]. The most recent Quarterly MDS dated [DATE] revealed that the resident had severe cognitive impairment and required extensive assistance with eating. The resident's current diet order was for a chopped Diet. Observation of an evening meal on 7/7/16 revealed that the resident was served a slice of pizza cut crosswise into three pieces. One of these pieces contained the edge of the crust which was not soft to chew and was intact. The resident was left unattended to feed herself independently. The resident made no attempt to eat the pizza. A staff member cut the pizza into small pieces after surveyor intervention. On 7/8/16 the resident was observed at a lunch meal to have whole fish and chips (French fries) on her plate. According to the menu for the chopped Diet and the resident's meal ticket, the chips and fish should have been chopped. These are considered to be crispy items and generally are not allowed whole on a chopped diet as noted above. The RD was interviewed on 7/8/16 during the lunch meal regarding the system in place to ensure the accuracy of the menu served. The RD stated that a dietary worker identifies the diet and if there are any deviations from the menu this worker would identify those deviations to the other dietary worker serving the food. There was no menu posted in the pantry or dining rooms on the fifth floor. The food was served by a dietary worker directly from the steam table in the pantry. The DON was interviewed on 7/8/16 at 3:50 PM and stated that the nursing staff is trained to identify errors related to diet and to have those errors corrected. Regarding the issue with the pizza, the DON asked if the covers were removed at the time of the observation. The surveyor informed her that they were. The DON then stated that the expectation would be that the nurse aides would cut up the pizza into small pieces. The Registered Nurse unit manager was interviewed on on 7/8/16 at 4:10 PM and revealed that Residents #8, #32 and #174 need assistance with cutting their food to the form and consistency prescribed by the physician. The Accident/Incident reports were reviewed for the past 12 months and there were no incidents related to choking or mechanical altered diets. 415.14(d)(3)

Plan of Correction: ApprovedAugust 2, 2016

The facility will ensure that food is served in a form designed to meet the needs of residents on mechanically altered/consistency diets on the dementia unit.
I. Corrective Action for Identified Residents
Resident # 49
Resident did not require any other intervention since she ate only those foods which were appropriate for her prescribed diet. The Registered Dietitian in-serviced the food service workers on site not to serve garlic bread unless on the resident?s diet ticket. The cook and cook?s helper were in-serviced by the RD to slice tomatoes instead of serving chunks and to remove skin from cucumbers and dice. All verbal in-services were done on 7/6/16.
Resident # 32
As stated in the SOD, a staff member cut the food into bite size pieces. The Registered Dietitian gave the cook?s helper an on-site in-service regarding the proper procedure to use to chop the pizza and the marinated vegetables. It was completed on 7/7/16.
Resident # 174
As stated in the SOD, a staff member cut the food into bite size pieces on 7/7/16. The Registered Dietitian gave the cook?s helper an on-site in-service regarding the proper procedure to chop the pizza and the marinated vegetables on 7/7/16.
On 7/8/16 a staff member did assist the resident. Also an in-service with written instructions and discussion was begun by the RD with food service workers to read the diet ticket completely on 7/8/16.
For All Residents (#6, 8, 32, 49 and 174)
Cooks and cook?s helpers had an on-site in-service by the RD on food preparation to ensure that food is prepared in a form designed to meet individual needs. This was completed on 7/6/16. An in-service with written instructions and discussion by the RD began for the cooks on 7/8/16.
Dietary Aides received an on-site in-service by the RD that they must read the diet tickets out loud completely to the server, check the meal tray against the diet ticket and make a correction if needed. The verbal in-service was given on 7/6 and an in-service with written instructions and discussion by the RD begun on 7/8/16.
II. Identification of other Residents
Any resident on a Soft to Chew or Chopped diet may be affected. The determination by the RD was completed on 7/11/16. All dietary aides were in-serviced by the RD that they must read the diet tickets out loud completely to the server, check the meal tray against the diet ticket and make a correction if needed.
III. Measures and Systemic Changes
1.All residents identified (Residents # 6, 8, 32, 49, 174) were screened by the Speech Pathologist to ensure that the appropriate consistency is ordered for each individual. All residents will remain on their ordered diets. Only Resident # 8 will be given a trial to evaluate her response to an upgrade of her diet from Soft to Chew to Regular. The screens were completed on 7/28/16. The evaluation of Resident #8 will be completed by 8/5/16.
2.The Registered Dietitian developed a policy and procedure to ensure that menus are posted in all food service preparation areas and service locations including the cooks? bulletin board, the steam table in the main kitchen, the 5th floor and 3rd floor kitchenettes, and the main dining room areas. This was completed on 7/8/16.
3.The food service workers job assignment was revised by the RD to include that the employee who is plating the foods must read the menu posted for the altered consistency diets beforehand. It was completed on 7/13/16.
4.The food service workers job assignment was revised by the RD to include that the person calling out the diet tickets would state to the server the name of the items to be given for each ticket, to check the meal plate against the diet ticket, and to make corrections to the plate if needed. It was completed on 7/13/16.
5.The recipe for tossed salad was reviewed with the cooks by the RD to ensure that the tomatoes would be sliced and the cucumber would have skin removed and chopped. The fish and chips menu was changed by the RD to baked breaded fish and baked potato. This was completed on 7/13/16.
6.Education began by the RD for all Dietary workers including the workers who provided the incorrect form and consistency of the meals served on the new P&P on where to read the posted menus and the revisions to the written job assignments. It was completed on 7/8/16.
7.Education began for the cooks by the RD on alternate consistency diets and the proper procedure to ensure the consistency is in the ordered form which began verbally on 7/6 and as a discussion with written instructions on 7/8/16.
IV. Monitoring of Corrective Actions
The Registered Dietitian developed an audit tool to monitor that planned meals are served in accordance to the planned menu.
The RD developed an audit tool to monitor that the cooks prepare the altered consistency foods according to the menus posted in the kitchen. This audit will be conducted by the FSS/designee through direct observation.
Supervisor will check the written menu posted in the kitchen to determine what food items are planned to be chopped, write the item on audit form provided, and check the food item(s) in the cook?s area.
FSS will check the food consistency of the altered consistency menu items to ensure that the food is in the proper consistency form.
If not prepared according to proper consistency, will in-service cook, and have item(s) prepared to proper consistency.
The RD developed an audit tool to monitor through direct observation by the Food Service Supervisors (FSS)/designee that:
The menu extensions are posted in all locations as per policy.
1. The food service worker who plates the food has read the posted menus.
2. The food service worker who calls out the diet ticket to the server is states the name of the food to be served.
3. The food service worker checks the diet ticket against the food that is plated.
4. The food service worker makes corrections to the plate if needed.
Audits with negative findings will have corrective actions immediately implemented by the Dietitian.

This was completed on 7/13/16.

Audit findings will be presented to the QAPI Committee monthly for the 1st three months for systematic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further audits. The Registered Dietitian or designee will complete all corrections by 9/9/16.

FF09 483.35(c):MENUS MEET RES NEEDS/PREP IN ADVANCE/FOLLOWED

REGULATION: Menus must meet the nutritional needs of residents in accordance with the recommended dietary allowances of the Food and Nutrition Board of the National Research Council, National Academy of Sciences; be prepared in advance; and be followed.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2016
Corrected date: September 9, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during a recertification survey, the facility did not ensure that planned menus were followed for 4 of 4 residents residing on the dementia unit (Residents #8, 32, 49 and 174) mechanically altered/consistency diets. The findings include: 1. Resident #49 has [DIAGNOSES REDACTED]. The resident's most recent physician's orders [REDACTED]. The resident was observed on 7/6/16 during a lunch meal eating in a unit dining room on the 5th Floor. According to the meal ticket that accompanied the resident's tray, the resident was to be served a Soft to Chew diet as prescribed by the physician. The items served to the resident included a tossed salad consisting of sliced cucumbers with skin and tomato wedges (not thinly cut) and oven-baked garlic bread. The resident was left to feed herself independently. The resident placed a tomato wedge in her mouth, ate the fleshy part and placed the remaining portion of the wedge back on her tray. Additionally, the resident was observed to place the garlic bread in her mouth and returned it to her tray without biting it. The Registered Dietitian (RD) who was present during the above meal observation was interviewed at that time and stated that garlic bread was not allowed for this resident. The menu for the Soft to Chew diet and the printed menu on the resident's meal ticket did not include garlic bread. 2. Resident #32 has [DIAGNOSES REDACTED]. The most recent physician's orders [REDACTED]. According to the facility's diet manual, this diet promotes self-feeding in that most items and certain vegetables are cut into bite-size pieces. The textures are soft with no tough skins; and dry, crispy or stringy foods are omitted. During the evening meal on 7/7/16 the resident was served a slice of pizza cut crosswise into three pieces. One of these pieces contained the edge of the crust which was not soft to chew and was intact. The resident was also served a regular marinated vegetable salad consisting of chunks or slices of vegetables. According to the menu for the chopped diet, the pizza and salad should have been served chopped. (The cheese on the pizza was mozzarella, which is generally stringy when heated.) It was observed during this meal that the resident was left unattended to feed himself independently. The residednt did not make any attempt to feed himself. After surveyor's intervention, a staff member cut the pizza into small pieces. 3. Resident #174 has [DIAGNOSES REDACTED]. The resident's current diet order was for a chopped Diet. Observation of the evening meal on 7/7/16 revealed that the resident was served a slice of pizza cut crosswise into three pieces. One of these pieces contained the edge of the crust which was not soft to chew and was intact. The resident was left unattended to feed herself independently. The resident made no attempt to eat the pizza. After surveyor's intervention the pizza was cut into small pieces. On 7/8/16 the resident was observed at the lunch meal to have whole fish and chips (French fries) on her plate. According to the menu for the chopped diet and the resident's meal ticket, the chips and fish should have been chopped. These are considered to be crispy items and generally are not allowed whole on a chopped diet as noted above. The RD was interviewed on 7/8/16 during the lunch meal regarding the system in place to ensure the accuracy of the form and consistency of the meal served. The RD stated that a dietary worker identifies the diet and if there are any deviations from the menu this worker would relay the information about the deviations to the other dietary worker serving the food. There were no menus for the mechanically altered/consistency diets posted in the pantry or dining rooms on the Fifth Floor. The food was served by a dietary worker directly from the steam table in the pantry. Three dietary workers were interviewed on 7/8/16 after the completion of that day's lunch meal: - the dietary worker who served the pizza on 7/6/16 stated that the menus are to be read to ensure that the menu is followed as written; - the dietary supervisor stated that the meal tickets are to be read; and - the dietary worker who served lunch on 7/8/16 stated that there was some confusion regarding the type of potatoes to serve on the chopped diet on 7/8/16. The unit Registered Nurse manager was interviewed on 7/8/16 at 4:10 PM and stated that Residents #8, #32 and #174 need assistance with cutting their food to the form and consistency prescribed by the physician. 415.4(c)(1-3)

Plan of Correction: ApprovedAugust 2, 2016

Planned menus will be followed for all residents on mechanically altered/consistency diets residing in the facility.
I. Corrective Action for Identified Residents
Resident # 49
Resident did not require any other intervention since she ate only those foods which were appropriate for her prescribed diet. The Registered Dietitian in-serviced the food service workers on site not to serve garlic bread unless on the resident?s diet ticket. The cook and cook?s helper were in-serviced to slice tomatoes instead of serving chunks and to dice and remove skin from cucumbers. All verbal in-services were completed on 7/6/16.
Resident #32.
As stated in the Statement of Deficiencies (SOD), a staff member cut the food into bite size pieces. The Registered Dietitian (RD) gave the cook?s helper an on-site in-service regarding the proper procedure to chop the pizza and the marinated vegetables. The verbal in-service was completed on 7/7/16.
Resident # 174
As stated in the SOD, a staff member cut the food into bite size pieces on 7/7/16. The Registered Dietitian gave the cook?s helper an on-site in-service regarding the proper procedure to chop the pizza and the marinated vegetables. This was completed on 7/7/16.
On 7/8/16 a staff member did assist the resident. Also an in-service with written instructions and with discussion was begun by the RD with food service workers to read the diet ticket completely on 7/8/16.
For All Residents (#8, 32, 49 and 174)
5th Floor Dietary Aides had an in-service that they must read the diet tickets out loud completely to the server, check the meal tray against the diet ticket and make a correction if needed. The verbal in-service was given by the RD on 7/6 and an in-service with written instructions and discussion was begun on 7/8/16.
II. Identification of Other Residents
Any resident on a Soft to Chew or Chopped diet may be affected. This determination by the RD was completed on 7/11/16. Dietary aides were in-serviced that they must read the diet tickets out loud completely to the server, check the meal tray against the diet ticket and make a correction if needed.
III. Measures and Systemic Changes
1.The Registered Dietitian developed a policy and procedure to ensure that alternate consistency menus are posted along with the regular menu in all food service preparation areas and service locations including the cooks? bulletin board, the steam table in the main kitchen, the 5th floor and 3rd floor kitchenettes, and the main dining room areas. It was completed on 7/8/16.
2.The food service workers job assignment was revised by the RD to include that the employee who is plating the foods must read the menu posted for the altered consistency diets beforehand. It was completed on 7/13/16.
3.The food service workers job assignment was revised by the RD to include that the person calling out the diet tickets would state to the server the name of the items to be given for each ticket, to check the meal plate against the diet ticket, and to make corrections to the plate if needed. It was completed on 7/13/16.
4.The recipe for tossed salad was reviewed with the cooks by the RD to ensure that the tomatoes would be sliced and the cucumber would have skin removed and chopped. It was completed on 7/12/16.
5.The menu has been changed by the RD from fish and chips to baked breaded fish and baked potato. This was completed on 7/12/16.
6.Education began for all Dietary workers by the RD including the workers who provided the incorrect form and consistency of the meals served, on the new P&P on where to read the posted menus and the revisions to the written job assignments on 7/8/16.
IV. Monitoring of Corrective Actions
The Registered Dietitian developed an audit tool to monitor
through direct observation by the Food Service Supervisors (FSS)/designee that:
1. The menu extensions are posted in all locations as per policy.
2. The food service worker who plates the food has read the posted menus.
3. The food service worker who calls out the diet ticket to the server states the name of the food to be served.
4. The food service worker checks the diet ticket against the food that is plated.
5. The food service worker makes corrections to the plate if needed.
The audit tool was completed on 7/13/16.
Audits with negative findings will have corrective actions immediately implemented by the Dietitian.
Audit findings will be presented to the QAPI Committee monthly for the 1st three months for systematic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further audits. The Registered Dietitian or designee will complete all corrections by 9/9/16.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit". 7.10, 18.2.10.1, 19.2.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2016
Corrected date: September 9, 2016

Citation Details

2000 Life Safety Code, NFPA 101 Section 19.2.10. Marking of Means of Egress. 19.2.10.1 Means of egress shall have signs in accordance with Section 7.10. Exception: Where the path of egress travel is obvious, signs shall not be required in one-story buildings with an occupant load of fewer than 30 persons. Section 7.10 Marking of Means of Egress 7.10.1 General 7.10.1.1 Where Required. means of egress shall be marked in accordance with Section 7.10 where required in Chapters 11 through 42. 7.10.1.2* Exits. Exits, other than main exterior exit doors that obviously and clearly are identifiable as exits, shall be marked by an approved sign readily visible from any direction of exit egress. 7.7.3 The exit discharge shall be arranged and marked to make clear the direction of egress to a public way. Stairs shall be arranged so as to make clear the direction of egress to a public way. Stairs that continue more than one-half story beyond the level of exit discharge shall be interrupted at the level of exit discharge by partitions, doors, or other effective means. Based on observation and interview, it was determined that service corridor doors leading to egress corridors that were not obviously and clearly identifiable as exits were not provided with exit signs, and that stairs that continued more than one-half story beyond the level of exit discharge were not interrupted at the level of exit discharge by a partition or other effective means. This was evidenced by signs lacking on the two doors in the service corridor outside the first floor kitchen that lead to lobby level egress corridors, and an uninterrupted stairwell in the same service corridor that lead to the lower level below. The findings are: On 7/8/16 during the life safety recertification survey, the 1st floor (lobby) area outside of the kitchen was toured and the following was noted: 1. There were two doors on opposite ends of the interior service corridor outside of the kitchen. These doors open into egress corridors that lead to the main entrance/exit. Neither of these doors were provided with exit signs. 2. There was an open stairwell in this same service corridor, leading to the lower level below. The stair was uninterrupted, i.e. a partition or door was not provided at the top of the stairs. In an interview at the time of the observations, the Maintenance Director stated that the interior corridor is used by staff only, but that exit signs can be installed if needed. 2000 LSC NFPA 101 - 19.2.10.1, 7.10.1.2, 7.7.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 29, 2016

I. Corrective Action for Cited Area
Signs were installed by the two doors in the service corridor outside the first floor kitchen. This was completed on 7/28/16.

A retractable barrier will be installed at the top of the uninterrupted stair in the same service corridor by 9/9/16.
II. Identification of Other Areas
The Director of Facilities completed an inspection of the entire facility to ensure any door, passage or stairway leading to an exit has an approved readily visible sign on 7/25/16.
The Director of Facilities also inspected the entire facility to ensure there are no other uninterrupted stairwells in the facility on 7/25/16.
III. Measures and Systemic Changes
1.The Director of Facilities installed signage that is readily visible from any direction on the 2 doors in the service corridor indicating that they are exits. This was completed on 7/28/16.
2.The Director of Facilities or his designee will install a retractable barrier at the top of the uninterrupted stair in the same service corridor by 9/9/16.
3.The Director of Facilities or his designee will monitor all exit signs on a monthly basis to ensure they are in good working order by 9/9/16.
4.The Director of Facilities or his designee will monitor the retractable barrier in the stairway by the service corridor to ensure it is in good working order by 9/9/16.
IV. Monitoring of Corrective Action
All exit signs and stairwell partitions or barriers will be surveyed monthly for the next 3 months to ensure the appropriate signage is in place and are functioning properly by either the Director of Facilities or his designee. Audits with negative findings will be corrected immediately. Audit findings will be presented to the QAPI Committee monthly for the first three months for systemic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further monitoring activities.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2016
Corrected date: September 9, 2016

Citation Details

713-1.18 Mechanical requirements. (d)(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 shown in Table 8. 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. (h) Ventilating, heating, and air conditioning systems. Such systems shall: (1) be maintained in good repair and shall be operated in a manner which will not allow for the spread of infection and provide for resident health and comfort; and (2) be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bath rooms, janitors' closets and soiled utility rooms or soiled linen rooms, to other parts of the facility. Based on observation and interview it was determined that the facility did not maintain the mechanical exhaust system in good working order necessary to ensure that the minimum number of fresh air changes were provided and that malodors were prevented. This was evidenced by non-functioning or malfunctioning exhaust systems in biohazard, trash, and housekeeping closets on 3 of 4 resident units (floors 2, 3, and 4). The findings are: On 7/6/16 and 7/7/16 during the life safety tour, malfuntioning exhaust was noted in the following locations: 4th floor: - On 7/6/16 at 11:45 AM, a malodor was noted in the B wing housekeeping closet. Upon examination by the Facilities Director, it was discovered that the exhaust vent was closed. According to the Facilities Director, he would have the vent opened as soon as possible. 3rd floor: - On 7/7/16 at approximately 10:20 AM, an odor was noted in the A wing biohazard closet. Upon examination by the Facilities Director it was determined that the draw on the exhaust was very weak. In an interview at the time of the observation, the Facilities Director explained that individual louvers on some of the exhaust units can be adjusted. He also stated that he will look into adding mushroom exhaust units where possible, i.e. if doing so would not interfere with the adjacent stairs. 2nd floor: - On 7/7/16 at 11:25 AM, the B wing trash room was toured and a malodor was noted. There was a full trash bin in the room. Upon examination by the Facilities Director, it was determined that the exhaust was not functioning. - At 11:35 AM the same day, a malodor was noted in the C wing housekeeping closet. A test of the exhaust system by the Facilities Director revealed that the exhaust was not working, and that the exhaust vent had been closed. He could not provide an explanation for why the vent had been closed. 415.29(h)(1)(2) 713-1.18(d)(2)

Plan of Correction: ApprovedJuly 29, 2016

The facility will maintain mechanical exhaust systems in good working order.
I. Corrective Action for Cited Areas
The Facilities Director opened the exhaust vent in the B wing housekeeping closet on the 4th floor and the C wing housekeeping closet on the 2nd floor. This was completed on 7/7/16.
He also adjusted the louvers on the exhaust vent in the A wing biohazard closet on the 3rd floor and the B wing trash room on the 2nd floor. This was completed on 7/13/16.
II. Identification of Other Areas
The Director of Facilities completed an inspection of all housekeeping, porters, trash and biohazard closets and storage areas to ensure proper exhaust on 7/25/16. An evaluation will be done on the best way to improve the exhaust in each area. Some might be improved by inline exhaust fans and others may need through the wall mushroom exhaust fans. The evaluation will be completed by 9/9/16.
III. Measures and Systemic Changes
Changes will be made upon evaluation by the Director of Facilities. A consultant will be called and depending on what the Director and Consultant deem the best solution, the required exhaust needed for each area will be obtained. The proper exhaust system will be installed for each area on an individual basis to manage the exhaust in the housekeeping, trash and biohazard closets.
IV. Monitoring of Corrective Actions
Once corrected, environmental rounds on these closets will be conducted monthly for the 1st 3 months to ensure proper functioning of the exhaust system. Audits with negative findings will be corrected immediately. Audit findings will be presented to the QAPI Committee monthly for the first three months for systemic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further monitoring activities.
Responsible Party and Completion Date
The Director of Facilities or designee will try to complete all corrections by 9/9/16. Due to the extensiveness of the work involved, and the facility?s reliance on an outside vendor to complete the work, the facility might require an extension beyond the 60th day from the survey exit date.
This P(NAME) constitutes the facility?s written credible allegation of compliance for the deficiencies cited. However, submission of this P(NAME) is not an admission that a deficiency exists or that one was cited correctly. This P(NAME) is submitted to meet requirements established by Federal & State law.