Capstone Center for Rehabilitation and Nursing
July 13, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during a recertification survey, the facility did not ensure comprehensive person-centered care plans were developed and implemented for each resident that included measurable observations and time frames to meet a resident's medical, nursing, mental and psychosocial needs for five (5) (Residents #30, #61, #62, #96 and #112) of twenty three (23) residents reviewed. Specifically: For Resident #'s 61 and 62, there were no dates on the care plans to indicate when interventions were initiated; for Resident #112, there were no interventions listed on the resident's care plans; for Residents #30, an end of life/hospice care plan was not initiated when the resident was placed on hospice services; and for Resident #96 the communication care plan did not have resident specific interventions to address the resident's communication needs. This is evidenced by: A Policy and Procedure for Care planning with a revision date of 12/2016, documented care plans are to be developed based on resident's Care Area Assessment Summary (CCA's), needs, desires, problems with appropriate interventions, and realistic goals. Resident #62 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum Data Set of 4/26/18, documented the resident had severe cognitive impairment. The resident rarely or never understood what was said to him by others and was rarely understood by others. The resident is on Comfort Care. The following care plans did not include dates when interventions were initiated: [DIAGNOSES REDACTED] Care Plan Pain Care Plan Comfort Care/End of Life Care Plan [MEDICAL CONDITION] Disorder: Potential for Injury Care Plan Use of [MEDICAL CONDITION] Drugs Care Plan Behaviors Care Plan Mood Care Plan Advance Directives Care Plan ADL Function Care Plan-no dates on page 1 At Risk for Alteration in Bowel Status/Function Care Plan At Risk for Bruising Care Plan At Risk for Falls Care Plan At Risk for Impairment of Skin Integrity Care Plan Nutrition Care Plan Potential to Abuse Others Care Plan Potential Victim of Abuse Care Plan During an interview on 07/11/18 at 09:31 AM, Registered Nurse Manager (RNM) #1 reviewed the resident's care plans and stated there were no dates documented to indicate when interventions were initiated. Registered Nurse Manager #1 stated the initiation dates should have been automatically entered when the intervention was started. She stated some of the dates come up, but some do not. She stated she will investigate why this is occurring. RNM #1 stated she had recently entered the intervention dates on the resident's care plans, however, the computer system did not save all of the dates. Resident #112 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS dated [DATE], documented the resident was severely impaired for cognition, sometimes was understood by others and sometimes was able to understand. The following care plans did not include interventions: Cognitive Loss/Dementia Care plan review date 3/20/18, Potential Victim of Abuse Care Plan dated 3/31/18. The following care plans dated 3/01/18, did not include interventions: Potential to Abuse Others Care Plan, Pain Care Plan, Elimination Care Plan, Dental Care Plan, Communication Care Plan, At Risk for Alteration in Bowel Status/function Care Plan, ADL Function Care Plan, Behaviors Care Plan, Risk for Compromised Respiratory Status, Alteration in GI Status Care Plan-GERD, Ulcers, Hernia, Depression Care Plan. Nutrition Care plan Cardiac potential for complications Care Plan During an interview on 07/13/18 at 10:38 AM, the Assistant Director of Nursing (ADON) reviewed the resident's care plans and stated there were no interventions in several of the resident's care plans. As an example, the ADON stated on Resident #112's Cardiac Care plan, interventions should have been personalized such as nursing monitors the resident's vital signs and monitors for chest pain. During an interview on 7/13/18 at 9:15 am, the Assistant Director of Nursing (ADON) reviewed the residents care plans and stated there were no interventions in several of their care plans. As an example, the ADON stated on Resident #112's Cardiac potential for complications Care plan, interventions should have been personalized such as nursing monitoring the resident's vital signs and nursing monitoring for chest pain. Interventions should be personalized based on the resident. She stated when the computer system changed to a different template, the dates should have been switched over. The computer system automatically enters the dates when an intervention is started. She stated the nurses should have entered the dates when it was noticed the dates were missing. Monthly audits of a sample of resident care plans is taking place. The nurses are also being re-educated. The corporation has stated they cannot enter the dates of the previously entered interventions. The dates were not integrated to a new template when they were moved over. The ADON stated it would be very difficult to go through 120 resident care plans and enter an accurate date when the interventions were initiated. Resident #96 The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The MDS on 6/6/18 assessed the resident sometimes understands, was sometimes understood, and had severely impaired decision making. The resident experienced verbal behaviors toward others on 4-6 days. During observation on 7/10/18 at 10:52 AM, Resident #96 was yelling and swearing in his room. Staff were in the room with him. RNM #2 walked by the room, heard the yelling and went in and calmed the resident down. The CCP for behaviors initiated 3/15/178, documented verbal aggression, socially inappropriate behavior, disruptive behavior related to [MEDICAL CONDITION], communication deficit, the resident yells out and this is usually to alert staff that he needs something. Interventions included: Approach in calm, positive manner; allow to express in appropriate ways; provide 1:1 as needed; reapproach as needed; observe for intent to harm self or others; monitor behaviors and update MD as needed; meds as ordered; monitor effectiveness of meds; divert attention, redirect; avoid over stimulation; take to another location; offer opportunities for reminiscence; praise progress. The CCP for Communication initiated 3/15/17, documented [MEDICAL CONDITION]. Goals were: Will have needs met; will comprehend. interventions included: anticipate needs; inform res of what is being done; understand residents frustration; allow time for resident to attempt words/gestures; use simple language; explain and speak clearly, face resident when speaking; speak slowly and enunciate distinctly; provide clues-point to items when discussing them; monitor for cerumen in ears and treat as appropriate; ensure comprehension of spoken word by asking for feedback. The resident's Care Card (used by caregivers to provide needed care) dated 6/21/18, documented the resident had [MEDICAL CONDITION], likes to get up between 6:00 and 6:30 am and would like to get ready for bed around 7:00 -7:30 pm every night and likes to wear a t-shirt not a hospital gown. He may wear slipper socks as desired. There was no other information about his communication needs or what to do when you can't understand the resident. During interview on 7/11/18 at 3:05 PM CNA # 5, who cares for the resident, said the resident yells; he can't speak many words; he can point but pointing does not tell you what he wants. You have to try to figure it out. He has behaviors (yelling, swearing) on evenings maybe daily or a couple of times a day. During interview on 7/11/18 at 3:19 PM, CNA #7 said the resident swears and yells in general. He does not refuse care for her. He swears at other residents, does not talk much, cannot tell you what he needs, gets aggravated if you cannot tell what he wants. She tells him to point to it. She thought the resident would be happier if could talk better. He wakes up at night and then yells. She said she was not aware of anything to help him communicate better. He understands us but we don't understand him. During interview on 7/11/18 at 3:41 PM, CNA #7 stated the resident yells when he wants your attention, he can't talk well. He knows if soiled and will yell. If you pull to hard on his bad arm he will swear. His care card does not tell us his right arm is bad. The CNA did not think anyone documented when the resident yells, that is the way he communicates, everyone is just used to that. Sometimes he will say hey when he wants something. He gets angry when people can't understand him, swear words come out really good. The CNA said the care card does not tell you some of this information to help you care for him. During interview on 7/13/18 at 10:32 AM, Social Worker #5 said the resident yells when he wants something, that is his means of communication. His wife is here daily and helps us with communication. She said if we cannot understand him, try to ask him every thing, name things until you get a yes. Normally wants to get up or go to his spot in hallway. He has two favorite spots. This information is important for care. The care care card provides the information needed by staff to provide care and should reflect this. She looked at care card in the computer, and said the language communication section needed to be more personalized for this resident, giving pointers from the resident's wife. During interview on 7/13/18 at 11:03 AM, RNM #2 said the aides can look at the profile care card, but not the care plans. RNM #2 said it is better to have information on the profile care card for staff, it is not there now. During interview on 7/13/18 at 1:00 PM, the Director of Nurses stated the resident has communication problems. She has learned what some of his yells mean. She was asked if this information should be in care plan/profile card for staff to use, and agreed that it should be. 10NYCRR415.11(c)(1)

Plan of Correction: ApprovedAugust 15, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** A QAPI meeting was conducted on [DATE] to identify causative factors contributing to the deficiencies.
The facility hired an outside consultant to develop and implement an acceptable plan of correction.
The following corrective actions have been implemented for those residents found to have been affected by the deficient practice:
? Resident #30 expired
? Resident #61 and #62 Care Plans were reviewed and revised to include dates on all interventions.
? Resident #96- Communication Care Plan was updated to include resident specific interventions and resident?s care card was updated to include resident specific interventions to address the resident?s communication needs.
? Resident #112- Cognitive Care Plan and Potential Victim of Abuse Care Plans were updated to include interventions and all other Care Plans were reviewed and updated to include dates on all interventions.
The facility recognizes that all residents have the potential to be affected by this alleged deficient practice. The corrective action will be:
? Care Plans for all residents will be reviewed to ensure dates of interventions are in placeand to ensure time frames and measurable goals/ observations are in place. Any components in need of correction will be corrected at that time.
? All residents on Hospice/Comfort Care will be reviewed to ensure an End of Life Care Plan is in place. Any missing care plans will be initiated at that time.
? All residents with Communication Care Plans and their Care Card will be reviewed to ensure resident specific interventions are in place to address the resident?s communication needs. Any identified areas of concern will be corrected at that time.
? All residents? Care Plans will be reviewed to ensure interventions are in place. Any identified areas of concerns will be corrected at that time.

The following systemic changes will be implemented to ensure that the alleged deficient practice does not recur:
? Care Planning, MDS Assessments and MDS Interviews Policy was reviewed and updated to include:
o Each residents? care plan will be reviewed by the IDT at each care conference to ensure care plans are in place for all potential and actual care areas, and include resident specific interventions with initial dates for each intervention, with time frames and measurable goals/ observations
o The resident care card will be reviewed by the IDT during care conference to ensure that applicable resident specific interventions are on the care card.
The Consultant that the facility has contracted with will complete the directed education as follows:
? All RNs and IDT will be educated on:
o Revised Policy on Care Planning, MDS Assessments and MDS Interviews
o Care Conference Process to include review of each care plan for completion, accuracy, and resident specific interventions
o Process to review and update resident care cards to include resident specific interventions during care conference
o When to do a care plan, how to initiate and update a care plan in the EMR, and how to complete resident specific care plans
o Required components of a Care Plan including: measurable goals, time frames and interventions
These corrective actions will be monitored through:
? CAA/Care Plan audit will be completed three times a week during each unit care conference for all residents reviewed.
? Audit will ensure that each resident will have a person-centered comprehensive care plan developed and implemented to meet their preferences and goals and address the resident?s medical, physical, mental, and psychosocial needs and includes measurable goals/observations and time frames for achieving resident goals

The efficacy of the corrective measures will be monitored and reviewed monthly by the Quality Assurance Performance Improvement Committee.
For continuous quality improvement the nature and frequency of the audits will be reviewed and revised as determined by the QAPI Committee.
Title of Person Responsible:
The ADON will be responsible for oversight and compliance of corrective action. If a problem is identified the DON will be notified to take immediate corrective action.
Completion Date: [DATE]

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation, staff interview, and record review during the recertification survey, essential equipment was not maintained in safe operating condition. All mechanical equipment is to be maintained in safe operating condition. Specifically, the kitchen utility mop sink was not in operational repair. This is evidenced as follows: The main kitchen was inspected on 07/11/2018 at 10:10 AM. A sign was noted on the kitchen janitor closet door that stated: Do Not Use Mop Sink. The Food Service Manager stated in an interview conducted on 0607/11/2018 at 10:10 AM, that the mop sink has not been operational for at least 1½ years and that she does not know of a work order to have the sink repaired. No facility work orders regarding the kitchen mop sink were available for survey review when requested on 07/11/2018. The Director of Plant Operations stated in an interview conducted on 07/11/2018 at 2:51 PM, that there are not work orders to replace the mop sink, but he found the replacement in the storage garage this past spring, but has not yet installed it. 10 NYCRR 415.5(e)(1)(2)

Plan of Correction: ApprovedAugust 6, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
The dietary mop drain was repaired during the time of survey.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by this deficient practice. All other department heads completed audit tool to identify if there were any issues with equipment safety or function and if a work order was completed for it.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Will implement a work order policy and educate all department heads on the new policy for initiating work orders.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
Monthly audit of department work orders to ensure work orders are responded to timely and all issues identified are put into a work order. Monthly audits will continue until facility QA committee determines an appropriate level of compliance where the frequency can be reduced.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
The date for the correction and the title of the person responsible for correction of each deficiency.
Date of Completion: 09/05/2018

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure a therapeutic diet was maintained for one (Resident #110) of one residents reviewed for hydration during the recertification survey. Specifically, the facility did not monitor Resident #110's physician ordered 1500 ml (milliliter) fluid restriction to ensure the resident received the amount of fluid ordered. This is evidenced by: Resident #110: The resident was admitted on [DATE], with [DIAGNOSES REDACTED]. The Minimum (MDS) data set [DATE], assessed that the resident understands and was understood, and had moderately impaired decision making ability. It documented the resident received a therapeutic diet. Physician orders [REDACTED].= 780 ml, dietary = 720 ml for end stage liver. Regular Diet. The Comprehensive Care Plan for Nutrition initiated 1/2/18, documented the resident received a fluid restriction of 1500 ml, with a goal of compliance with fluid restriction. An intervention included to provide diet as ordered. The evaluation notes documented: 2/5/18 - the resident was readmitted and a fluid restriction of 1000 ml was added. On 3/26/18, the fluid restriction was updated to 1500 ml. During observation on 7/10/18 at 11:52 AM, the resident had many Ensure Plus, at least a dozen bottles, and water bottles, at least 6-8 bottles, on his dresser. This was also observed on 7/11/18 at 8:58 AM. On 7/11/18 at 9:00 AM, the resident's diet ticket was at the nursing desk. The fluid intake recorded on it was 420 ml even though the ticket called for the resident to get only 8 oz (240 ml) of cranberry juice. At this time, Certified Nurse Aide (CNA) # 5 was asked if the resident was on a fluid restriction. CNA #5 looked at the profile card (provides instructions for resident care) in the computer and stated the resident was on 1500 ml restriction. On 7/11/18 at 12:43 PM, the resident's lunch tray had an 8 oz (240 ml.) of diet gingerale on it. On 7/13/18 at 8:37 AM, the resident was in bed dozing. There was a 9 oz (270 ml.) plastic glass of water half full, a 9 oz plastic glass 1/3 full of a pink liquid and a large styrofoam cup with liquid that was half full. It had the resident's name and 7/13/18 written on it. A CNA then brought the resident's breakfast tray in. It only had 8 oz of cranberry juice on it. Daily computerized Food/Fluid records from 5/1-7/12/18 documented: not all meals were recorded; totals for some meals exceeded the 240 ml allotted by dietary for each meal; not all nursing fluids given to the resident were included in the documentation. During interview on 7/13/18 at 8:40 AM, CNA #6 said the styrofoam cups are left by the overnight aide for every resident. She said the resident likes cranberry and apple juice. The resident will go to the refrigerator and get himself a drink. At 10:00 AM they pass out snacks, he gets a snack and a drink. She said the nourishments and drinks are put in the computer. We are supposed to keep tract of every drink he has. The styrofoam cup is 420 ml. She was asked how they knew how much the resident was drinking. She said they would have to monitor, but did not know if the nurse was doing that. She looked at fluids on the resident's tray and overbed table and said that amount of fluid was more than he should have. During interview on 7/13/18 at 10:19 AM, the Food Service Director stated the resident gets 240 ml (8 oz.) on each tray and nothing else from dietary. The large styrofoam cups are used by nursing, not dietary. They replaced the water pitchers they used to use. If the resident is on a fluid restriction they should not have one of those cups. During interview on 7/13/18 at 12:26 PM, Licensed Practical Nurse #5, stated the resident is waiting for a liver transplant and that the resident is on a 1500 ml fluid restriction per day. she looked in the computer and said she could not tell how much fluid nursing should be giving the resident. During interview on 7/13/18 at 12:29 PM, the Registered Nurse Manager stated the resident is on fluid restriction due to ascites, they are trying to keep fluid build up in the abdomen down. She stated the Ensure and water on the resident's dresser have been there a long time, he does not drink them. She said staff put the styrofoam container of fluid in the resident's room, they should not have. She had educated staff on fluid restrictions. They have a fluid alert system in the computer that will flag if intake is under or over. She looked at the previous day (12 th) and said there was only one documentation of fluid with medication so the daily total was not an accurate record. The resident receives medication 4 times a day. She said you have to go into alerts section to see if there is a fluid problem. She does check them regularly. She said nursing gets 780 ml for meds, but not sure how that amount was broken up for each time medications were given. She looked in the computer and could not find that information. 10NYCRR415.12(i)(1)

Plan of Correction: ApprovedAugust 6, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Resident # 110 was seen by the physician and fluid restriction order was changed on 07/17/18 to 2000ml per day. On 08/02/18 the fluid restriction order was reviewed and revised to include how many ml per shift to be provided. Resident #110 care plan was revised to include his preference to obtain fluids on his own throughout the day and history of having bottle of fluids in his room but not drinking them.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents on fluid restrictions have the potential to be affected by this deficient practice. The facility did a full house audit and there are no other residents on fluid restrictions.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
A full house audit was completed on 08/02/18 to identify any other individuals on fluid restrictions. Staff will be re-educated on fluid restrictions and documentation of fluid intake.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit will be completed of any residents on fluid restrictions and the documentation of fluids provided each shift. The audit will continue monthly until the QAPI committee determines an appropriate level of compliance where the frequenct of the audit may be reduced.
The date for the correction and the title of the person responsible for correction of each deficiency.
The Diet Tech will be responsible for this monthly audit to be reported at monthly QA.
Date of Completion: 09/05/18

FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: §483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- §483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. §483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; §483.10(i)(3) Clean bed and bath linens that are in good condition; §483.10(i)(4) Private closet space in each resident room, as specified in §483.90 (e)(2)(iv); §483.10(i)(5) Adequate and comfortable lighting levels in all areas; §483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and §483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the facility did not provide effective housekeeping and maintenance services. Specifically, floors and walls were not clean and in good repair on 3 of 3 resident units. This is evidenced as follows. The resident area floors and walls were spot checked on 07/13/2018 at 8:30 AM. The corridor and common area floors next to walls were soiled with a brown build-up next to walls and at door thresholds on resident units on floors 2, 3, and 4 (1st floor is the basement floor). The floors in resident rooms 237, 272, 274, 383, 479, and 487 were not clean. The floor in resident room [ROOM NUMBER] was sticky. The walls were scraped and/or had peeling coving base in resident rooms 235, 270, 287, 358, 454, and 474. The Director of Plant Operations stated in an interview conducted on 07/13/2018 at 8:30 AM, that the walls are in the process of being repaired and painted, he sees were the floors require cleaning where survey noted today, and that his department is no long responsible for cleaning the floors. 483.10(i)(2)

Plan of Correction: ApprovedAugust 6, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by the deficient practice. Rooms 237, 272, 274, 383, 479, 487 and 489 room floors were cleaned by housekeeping staff. Strip and wax resident rooms 237, 272, 274, 383, 479, and 487 will be completed by 09/05/18.
The stripping and waxing of these rooms will include complete base board cleaning including all doorway thresholds.
Rooms 235, 270, 287, 358,454 and 474 cover base and walls will be patched painted and repaired.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house check of resident rooms, halls, common areas for cleanliness and walls in good repair will be completed to identify any other areas in need or repair or cleaning.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Housekeeping staff will be educated on room and floor cleaning. Maintenance staff will be educated on room/ wall repairs. All staff will be educated on putting in work orders for rooms with cove base, peeling, wall damage or other items that may inhibit the residents from having a safe, clean, comfortable, homelike environment.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of 10% of resident rooms, common areas or corridors will be completed. Room and corridor audits will include cleanliness of floors, condition of floors, condition of cove base, condition of walls. Audits will be presented during monthly QA until the facility has reached an acceptable level of compliance at which time the QAPI committee will then determine the frequency of the audits.
The date for the correction and the title of the person responsible for correction of each deficiency.
The Director of Housekeeping is responsible for corrective action of this deficiency.
Date of Completion 09/05/2018

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and employee interview during the recertification survey, the facility did not utilize power strips in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.2.3.6 and The Centers for Medicare and Medicaid Services notice from the Director of the Survey and Certification Group S&C 14-46-LSC permits the use of Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1 to power patient care-related electrical equipment and Relocatable Power Taps (RPT) listed as UL 1363 to power non-patient-care related electrical equipment. NFPA 70 National Electrical Code 2011 Edition Articles 400.8, 400.7, and 368.56(B) require that relocatable power taps (power strips) be secured to the wall. Specifically, non-compliant power strips were used to power patient care equipment and other electrical devices in patient care areas, and power strips in use throughout the facility were not secured as required. This is evidenced as follows: A sample of resident care areas were inspected for use of power strips on 07/13/2018 at 8:30 AM. The same non-compliant power strip was used to power a medical device (nebulizer) and non-medical devices (fan, personal electronics) in resident room [ROOM NUMBER]. Both a medical device (nebulizer) and non-medical device (table fan) were plugged into the same power strip (UL 1363A) in resident room [ROOM NUMBER]. Throughout the facility in offices, power strips were not attached to the wall. The Director of Plant Operations stated in an interview conducted on 07/13/2018 at 10:30 AM, that power strips in offices are not attached to the wall, and he will take care of the power strips in the resident rooms. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.2.3.6; 2011 NFPA 70 400.8, 400.7, 368.56(B);10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 3-3; 1999 NFPA 70

Plan of Correction: ApprovedAugust 13, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by this deficent practice. room [ROOM NUMBER] and room [ROOM NUMBER] power strips were attached to the wall and medical and non-medical
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All resident rooms and offices will be checked to ensure power strips are attached to the wall and to ensure medical and non-medical equipment are not plugged in to the same power strips.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Staff will be re-educated related to plugging in medical and non-medical equipment.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of 10% of resident rooms or offices will be completed monthly to ensure any power strips are mounted and that medical and non-medical equipment are not plugged in.Monthly audit to be reported at monthly QA. QAPI committee will determine when an appropriate level of compliance is reached and if frequency of audits may be changed.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation, employee interview, and record review during the recertification survey, the facility did not maintain patient care-related electrical equipment (PCREE) in accordance with adopted regulations. NFPA 99 Standard for Health Care Facilities 2012 Edition section 10.3 requires that facilities maintain PCREE with consideration of the owner's manuals. Specifically, PCREE such as nebulizers, were not maintained as prescribed in the owner's manuals. This is evidenced as follows: Residents were present during all observations. Observations on 07/13/2018 at 8:30 AM, revealed the electric inhalation-treatment nebulizers assigned to residents in rooms 270, 335, 354, 358, and 360 were not in use and plugged into an electrical outlet. Review of each nebulizer owner's manual 07/13/2018, revealed that to reduce the risk for electrocution, each unit is to be unplugged immediately after use. The Nurse Educator stated in an interview conducted on 07/13/2018 at 11:30 AM, that staff receive no specific training to unplug the nebulizers when not in use and the owner's manuals are consulted for information on the safe use of PCREE. Suction machine # , assigned to the 3rd floor unit dining room was checked and the instruction manual was reviewed on 07/16/2018 at 10:55 AM. A hydrophobic bacteria filter (filter) was not attached between the collection canister and pump. The instruction manual states that a filter is required between the canister and pump. The Assistant Director of Nursing stated in an interview conducted on 07/16/2018 at 10:55 AM, that the suction machine was ready for instant use and that the filter should have been in place. 42 CFR 483.70 (a) (1); 2012 NFPA 99 10.3; 10 NYCRR 713-1.1, 711.2 (19); 1999 NFPA 99 7-5.1.3

Plan of Correction: ApprovedAugust 6, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
A manual binder for medical equipment will be placed at the front desk for nursing staff to reference as needed. All licensed staff will be re-educated on unplugging nebulizers after use, suction machine filters/ parts and other manufacture recommendations related to medical equipment and location of the manual binder by 09/05/18.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of medical equipment use for 10% of resident rooms and all suction machine on the units will be completed monthly until the facility QAPI committee determines an acceptable level of compliance and reduces the frequency of the audit.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Education
Date of Completion: 09/05/18

EP TRAINING PROGRAM

REGULATION: *[For RNCHIs at §403.748, ASCs at §416.54, Hospitals at §482.15, ICF/IIDs at §483.475, HHAs at §484.102, "Organizations" under §485.727, OPOs at §486.360, RHC/FQHCs at §491.12:] (1) Training program. The [facility] must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the [facility] must conduct training on the updated policies and procedures. *[For Hospices at §418.113(d):] (1) Training. The hospice must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing hospice employees, and individuals providing services under arrangement, consistent with their expected roles. (ii) Demonstrate staff knowledge of emergency procedures. (iii) Provide emergency preparedness training at least every 2 years. (iv) Periodically review and rehearse its emergency preparedness plan with hospice employees (including nonemployee staff), with special emphasis placed on carrying out the procedures necessary to protect patients and others. (v) Maintain documentation of all emergency preparedness training. (vi) If the emergency preparedness policies and procedures are significantly updated, the hospice must conduct training on the updated policies and procedures. *[For PRTFs at §441.184(d):] (1) Training program. The PRTF must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) After initial training, provide emergency preparedness training every 2 years. (iii) Demonstrate staff knowledge of emergency procedures. (iv) Maintain documentation of all emergency preparedness training. (v) If the emergency preparedness policies and procedures are significantly updated, the PRTF must conduct training on the updated policies and procedures. *[For LTC Facilities at §483.73(d):] (1) Training Program. The LTC facility must do all of the following: (i) Initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected role. (ii) Provide emergency preparedness training at least annually. (iii) Maintain documentation of all emergency preparedness training. (iv) Demonstrate staff knowledge of emergency procedures. *[For CORFs at §485.68(d):](1) Training. The CORF must do all of the following: (i) Provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. All new personnel must be oriented and assigned specific responsibilities regarding the CORF's emergency plan within 2 weeks of their first workday. The training program must include instruction in the location and use of alarm systems and signals and firefighting equipment. (v) If the emergency preparedness policies and procedures are significantly updated, the CORF must conduct training on the updated policies and procedures. *[For CAHs at §485.625(d):] (1) Training program. The CAH must do all of the following: (i) Initial training in emergency preparedness policies and procedures, including prompt reporting and extinguishing of fires, protection, and where necessary, evacuation of patients, personnel, and guests, fire prevention, and cooperation with firefighting and disaster authorities, to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles. (ii) Provide emergency preparedness training at least every 2 years. (iii) Maintain documentation of the training. (iv) Demonstrate staff knowledge of emergency procedures. (v) If the emergency preparedness policies and procedures are significantly updated, the CAH must conduct training on the updated policies and procedures. *[For CMHCs at §485.920(d):] (1) Training. The CMHC must provide initial training in emergency preparedness policies and procedures to all new and existing staff, individuals providing services under arrangement, and volunteers, consistent with their expected roles, and maintain documentation of the training. The CMHC must demonstrate staff knowledge of emergency procedures. Thereafter, the CMHC must provide emergency preparedness training at least every 2 years.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on staff interview and record review during the recertification survey, the facility did not comply with the minimum emergency preparedness requirements. Specifically, the Emergency Plan, Training Program did not provide initial training for all existing staff in emergency preparedness policies and procedures consistent with their expected roles. This is evidenced as follows: A review of the Emergency Plan, Training Program documentation of staff training on 07/12/2018, revealed that 34 of 91 staff did not receive annual training in emergency preparedness policies and procedures. The Administrator stated in an interview conducted on 07/12/2018 at 8:30 AM, that not all the currently employed staff received the training. 42 CFR: 483.73(d)(1)(ii)

Plan of Correction: ApprovedAugust 6, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
All staff will be educated on the emergency operation plans and receive a post-test.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of new hires education on the emergency plan will be completed to ensure all staff received necessary education on the emergency operations plan.Monthly audit to be reported at QA. Audits will continue monthly until the facility QAPI committee determines if the frequency may be changed.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Education
Date of Completion: 09/05/18

POLICIES/PROCEDURES-VOLUNTEERS AND STAFFING

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (6) [or (4), (5), or (7) as noted above] The use of volunteers in an emergency or other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency. *[For RNHCIs at §403.748(b):] Policies and procedures. (6) The use of volunteers in an emergency and other emergency staffing strategies to address surge needs during an emergency. *[For Hospice at §418.113(b):] Policies and procedures. (4) The use of hospice employees in an emergency and other emergency staffing strategies, including the process and role for integration of State and Federally designated health care professionals to address surge needs during an emergency.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on interview and record review during the recertification survey, the facility did not comply with the minimum emergency preparedness requirements. Specifically, the Emergency Plan, policies and procedures did not include the use of volunteers, such as State and Federal health care professional to address surge needs, in an emergency. This is evidenced as follows: A review of the Emergency Plan on 07/12/2018, revealed the policies and procedures did not include the use of medical volunteers to address an influx of patients or residents and did not define the use of non-medical volunteers. The Administrator stated in an interview conducted on 07/12/2018 at 8:30 AM, that the Emergency Plan will be revised to include the use of medical and volunteers in the event of a surge emergency. 42 CFR: 483.73(b)(6)

Plan of Correction: ApprovedAugust 13, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All residents have the potential to be affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Facility emergency volunteer policy will be updated, all staff will be educated on new medical volunteer policy related to emergency planning.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
After implementing the policy, the emergency plan will be reviewed annually by the facility Safety Committee. The facility will develop an annual checklist of areas of the disaster plan to be reviewed.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview during the recertification survey, the automatic sprinkler system was not maintained in accordance with adopted regulations. NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems 2011 Edition Section 5.2.1.1.1 requires that sprinkler heads be free of foreign materials, such as dust. Specifically, sprinkler heads were found with a coating of dust. This is evidenced as follows: The sprinkler system was spot checked on 07/16/2018 at 8:10 AM. One sprinkler head each was found with a coating of dust in resident rooms [ROOM NUMBER]. The Director of Plant Operations stated in an interview conducted on 07/16/2018 at 8:10 AM, that he will have to check all sprinkler heads since apparently the sprinkler heads that were found dusty are by ventilation ducts. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.5; 2011 NFPA 25 5.2.1.1.1; 10 NYCRR 415.29, 711.2(a)(1); 2000 NFPA 101 19.7.5; 1998 NFPA 25 2-2.1.1, 2-4.1.8

Plan of Correction: ApprovedAugust 13, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
Sprinkler heads in rooms 337,379 and 381 had dust removed.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house check of all sprinkler heads was completed to ensure no other sprinkler heads were found with dust on them, any other sprinklers heads with dust on them had the dust removed.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur? Maintenance staff will be re-educated on dust removal of sprinkler heads.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
A monthly audit of sprinkler heads to ensure there is no dust on them will be reported during QA unit the QAPI committee determine an appropriate level of compliance is reached and may change the frequency of the audit.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18

K307 NFPA 101:SPRINKLER SYSTEM - SUPERVISORY SIGNALS

REGULATION: Sprinkler System - Supervisory Signals Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, National Fire Alarm and Signaling Code, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation and interview during the recertification survey, it was determined that the facility did not maintain the sprinkler system in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition section 9.7.2.1 requires that control valves servicing sprinkler systems be monitored with supervisory attachments having a distinctive signal to indicate an impairment of the operation of the sprinkler system that sounds and is displayed at a location that is constantly attended by qualified personnel. Specifically, two sprinkler system control valves were not monitored with supervisory attachments, and the supervisory signals for the monitored control valves are not located at a constantly attended location. This is evidenced as follows: The Director of Plant Operations stated in an interview conducted on 07/16/2018 at 11:15 AM that the automatic sprinkler system is fed by a 60,000 gallon holding tank and this holding tank is filled via the domestic water service. The sprinkler system was checked on 07/16/2018 at 11:15 AM. Two control valves, located in the Boiler Room, were found on the domestic water lines that fill the sprinkler system holding tank and did not have supervisory attachments. The Director of Plant Operations stated in an interview conducted on 07/16/2018 at 1:00 PM, that all other sprinkler system control valves have supervisory attachments that signal at the front desk, a location that is not constantly monitored. 42 CFR 483.70 (a) (1); 2012 NFPA 101 9.7.2.1; 2010 NFPA 72; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.7.2.1, 9.7.2.1; 1999 NFPA 72

Plan of Correction: ApprovedAugust 22, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All resident have the potential to be affected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
All resident have the potential to be affected by this deficient practice.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Facility Maintenance Director will reach out to Alarm System contractor to identify all sprinkler control valves and ensure all sprinkler control valves have electronic supervisory attachments in accordance with NFPA 101.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
An audit of sprinkler system control valves will be completed monthly until the QAPI committee determine an appropriate level of compliance is reached.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain smoke barriers in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 Edition Section 8.3.5.6.3 restricts the installation of metal electrical boxes in smoke barrier walls when the required fire resistance of the smoke barrier wall is reduced. Section 8.5.2.2 requires that smoke barriers shall maintain a minimum fire-resistance rating and shall be continuous from floor to the underside of the roof and through all concealed spaces. Specifically, in 1 of 1 smoke barriers observed, metal boxes were not fire protected, the wall was not continuous, and the fire-resistance rating was not maintained. This is evidenced as follows: The 3rd Floor-Unit smoke barrier wall (wall) was inspected on 07/16/2018 at 8:10 AM. In the corridor, an 8-foot by 3-inch space where the wall meets the underside of the floor/ceiling assembly was filled with mineral wool insulation only and not with a UL-Approved fire-stopping system. In resident room 337, the space around the ventilation duct was sealed with joint compound only and in other sections, fire-caulking was not applied with a smooth finish. One 24 square-inch metal electrical box was found each in resident rooms 337, 379, and 381; these metal electrical boxes were not fire-protected. The Director of Plant Operations stated in an interview conducted on 07/16/2018 at 8:10 AM, that he will properly fire-seal the electrical boxes and the space found in the corridor. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.7.3, 8.3.5.6.3, 8.5.6; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.7.3, 8.3

Plan of Correction: ApprovedAugust 21, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice?
All residents have the potential to be affected by this deficient practice. 3rd floor unit smoke barrier wall identified during survey will be repaired to ensure it is in compliance. Rooms 337, 379 and 381 electrical boxes to ensure penetrations in smoke barrier walls are sealed with a UL-Approved fire-stopping system
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A full house check of all smoke barriers to ensure penetrations in smoke barrier walls will be sealed with a UL-Approved fire-stopping systemwill be completed by 09/05/18.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Maintenance staff will be re-educated on smoke barriers and ensuring penetrations in smoke barrier walls will be sealed with a UL-Approved fire-stopping system.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
After any repairs with the full house audit, the facility will audit any new work done to the building to ensure no new areas are in new of repair, this will be reported monthy until the QAPI committee determines an appropiate level of compliance is reached and the frequency may be reduced.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 13, 2018
Corrected date: September 5, 2018

Citation Details

Based on observation and staff interview during the recertification survey, the facility did not maintain vertical openings in accordance with adopted regulations. NFPA 101 Life Safety Code 2012 edition sections 8.6.1 and 8.5 require that penetrations and miscellaneous openings in vertical opening walls, including rated ceiling assemblies, shall be fire-sealed. Specifically, rated ceiling assemblies were not continuous and did not maintain a 1-hour fire resistance rating. This is evidenced as follows: Observations above the suspended ceiling in the 3rd floor shower room on 07/16/2018 at 10:00 AM, revealed one 5-inch and one 3-inch unsealed hole for utility piping in the floor/ceiling assembly between the 3rd and 4th floors. The Director of Plant Operations stated in an interview conducted on 07/16/2018 at 10:00 AM, that he will seal the holes found in the ceilings. 42 CFR 483.70 (a) (1); 2012 NFPA 101 19.3.1, 8.6.1, 8.5; 10 NYCRR 415.29, 711.2(a) (1); 2000 NFPA 101 19.3.1.1, 8.2.5.2, 8.2.3

Plan of Correction: ApprovedAugust 21, 2018

What corrective actions will be implemented for those residents found to have been affected by the deficient practice? All residents have the potential to be affected by this deficient practice.
How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken?
A check of all vertical openings was completed to ensure no other areas were affected. An audit of all floor-ceiling assemblies to ensure penetrations are sealed with a UL-Approved Fire Stopping System will be completed by 09/05/18.
What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not reoccur?
Maintenance staff will be re-educated on proper enclosure and 2 hour fire rating of vertical openings by 09/05/18.
How the corrective actions will be monitored to ensure the deficient will not reoccur, i.e., what quality assurance program will be put in place?
Monthly audit of any new work completed to ensure follow up and that no new areas within the vertical opeenings need to be fire sealed. Monthly audits will continue until facility QAPI committee determines an appropirate level of compliance and if the frequency can be changed.
The date for the correction and the title of the person responsible for correction of each deficiency.
Director of Maintenance
Date of Completion: 09/05/18