New Vanderbilt Rehabilitation and Care Center, Inc
November 20, 2018 Certification Survey

Standard Health Citations

FF11 483.25(d)(1)(2):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: §483.25(d) Accidents. The facility must ensure that - §483.25(d)(1) The resident environment remains as free of accident hazards as is possible; and §483.25(d)(2)Each resident receives adequate supervision and assistance devices to prevent accidents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record reviews, and interviews, during the recertification survey, the facility did not ensure that each resident received adequate supervision and that the residents' environment remain free to prevent accident hazards. Specifically, the facility did not have clear policies and procedures to prevent residents from storing lighting material on the units. Residents who were known to keep lighting materials on their persons and in their rooms were provided with Out on Pass Privileges, but were not adequately monitored and/or supervised upon return to the facility, to ensure lighting materials were safely stored by facility. In addition Direct Care Nursing Staff found lighting material in rooms of such identified residents and did not report findings to Supervisors/Managers. This was evident for two (#156 and #228) out of three residents reviewed for smoking. The facility's policy and procedure Resident Smoking revised (MONTH) (YEAR) documented it is the purpose of the facility to provide residents who elect to smoke a safe smoking environment. Will ensure that residents who elect to smoke to conform with the facility's policies related to same. All identified smokers who smoke on facility premises will be supervised. The facility's policy and procedure Out on Pass dated (MONTH) (YEAR) documented Resident may leave the premises for days or part of a day by signing the Therapeutic Leave/ OOP form. There must be a written physician order [REDACTED]. The findings are: 1. Resident #228 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITIONS], Anxiety disorder, Essential Hypertension, Major [MEDICAL CONDITION], other chronic post procedural condition, [MEDICAL CONDITION]. The Quarterly Minimum Date Set ((MDS) dated [DATE] documented the resident as cognitively intact; requiring supervision with setup only for bed mobility, transfers, eating, and toilet use. Urinary and bowel is always continent. On 11/15/18 at 10:29 AM, the resident stated she was holding unto cigarettes and lighters and that staff are aware. The Smoking Assessment which is conducted quarterly for resident #228 was conducted on 10/19/17, 11/9/17, 5/4/18, 7/17/18 and 10/15/18. For question #15 on the Smoking Assessment it is asked Does the Resident attempt to hide/hold own lighters, cigarettes? The question was answered yes on all aforementioned quarters with the exception of 10/15/18, which was answered no. The resident was assessed as requiring supervision for smoking, however the resident declined to sign the Facility Smoking Contract on 10/17/17 and most recently on 11/20/18. The resident is classified as a smoker who has Out on Pass privileges. On 11/20/18 at 12:45 PM, an interview was conducted with Certified Nursing Assistant (CNA #2) who has worked [AGE] years for the facility and 2 months on the floor with the resident. CNA #2 stated that residents are supposed to give their cigarettes and lighter to the recreation department and that cigarettes and lighters should not be stored on the unit. CNA #2 also stated that the resident throws staff out of her room and will only enter the room when responding to the call bell. As per CNA #2 she has not observed or has searched this resident's room for cigarettes and lighters. CNA #2 stated the resident performs activities of daily living (ADL) care independently. 2. Resident #156 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. [MEDICAL CONDITION], Hypertension, [MEDICAL CONDITION] disorder, current episode depressed mild, [MEDICAL CONDITION], uncomplicated, [MEDICAL CONDITION], other [MEDICAL CONDITION], Pain unspecified, Other chronic pain, Paranoid [MEDICAL CONDITION], Diarrhea, [MEDICAL CONDITION], nicotine dependence, unspecified, uncomplicated. The Quarterly Minimum Date Set ((MDS) dated [DATE] documented the resident as cognitively intact; requiring bed mobility, transfers, eating, toilet use supervision with setup only. The Smoking Assessment which is conducted quarterly for resident #156 was conducted on 5/21/18, 8/21/18, and 11/20/18. For question #15 on the Smoking Assessment it is asked Does the Resident attempt to hide/hold own lighters, cigarettes? There was No for all referenced. The Facility Smoking Contract for the resident dated 11/20/18 and 2/24/17 was signed by resident. The resident was classified as smoker and granted with Out on Pass privileges. On 11/14/18 at 11:46 AM and interview with the resident stated he keeps the lighter and cigarettes during the day on his person and at night hiding it in the drawer. On 11/14/18 at 02:36 PM, the resident stated he has not told staff that he has cigarettes/lighters holding but stated that staff has observed him with cigarettes in hand, for example having a cigarette in my hand while getting off the elevator heading to the smoking area. The resident stated only the DNS, the Administrator, and Social Worker has told him that he is not supposed to have it, and should leave it with security, and if I do not it is going to cause my privileges to be taken away. The resident stated unannounced room checks has occurred when I am observed with a cigarette or when they suspect a resident is hiding it. He stated residents have stopped leaving their cigarettes and lighters with security because it disappears, and the facility does not reimburse the items. The resident stated since (MONTH) of last year he no longer leaves the lighter and cigarettes with security. On 11/20/18 at 10:59 AM, the resident stated being informed by the facility that the state is asking questions and the smoking rules about holding unto cigarettes and lighters will be enforced. The surveyor observed the Resident give the out on pass document to the security guard and proceeded outside. Outside on the facility's parking lot, the surveyor asked the resident are you about to smoke, do you have the cigarette and lighter, the resident replied I forgot the lighter. The resident returned to the security guard to obtain his lighter contained in a zip lock bag with resident's name on it; the security guard stated when you return make sure you return the lighter. On 11/20/18 at 12:58 PM, an interview was conducted with the Licensed Practical Nurse (LPN #2) who has worked for the facility for 3 years and greater or equal to a year on the unit was interviewed. LPN #2 stated some residents are supervised by recreation staff during the specified smoking time, residents' cigarettes and lighters are held by the recreation department and cigarettes and lighters cannot be on the unit. LPN #2 confirmed that CNA #2 had given her a lighter found in a resident's room (believes it was resident #156) followed by LPN #2 informing security and the recreation department, re-educating the resident about the smoking policy such as not supposed to have the lighter in the room and it must be kept downstairs. LPN #2 stated CNAs and LPNs conducted random room searches in (YEAR) but did not document nor inform the supervisor. On 11/20/18 at 02:06 PM, an interview was conducted with Nursing Care Coordinator (NCC) who stated supervise smoking residents go down stairs to the patio at specified times where recreation staff gives them their cigarettes and lighter and supervise them, then the residents return to the unit about twenty minutes later. The NCC stated cigarettes and lighters are not kept on the unit. Random room checks which involve checking resident rooms including the night tables and closets are based on if there is an identified problem. The NCC stated checks are not conducted without a reason, that is they are not routinely done. The NCC stated that this is because the security holds cigarettes and lighters of residents who go out on pass, they are required to give cigarettes and lighters back to security upon returning from out on pass. As per NCC, if I am not told it is a problem then it is not a problem; and it possible that residents can return to the floor with paraphernalia. NCC identified resident #228 and #156 as out on pass smokers and was informed by the surveyor that these residents stated they were holding paraphernalia in their rooms. The facility did not provide a policy or procedure to address residents who may go out and purchase smoking and lighting paraphernalia while out on pass. The facility has no formal policy regarding room checks for residents who refuse to sign smoking contract, or who are identified smokers with out on pass privileges. On 11/20/18 at 02:20 PM, an interview was conducted with a security guard who has worked at the facility since (MONTH) 2012. The Security guard's role includes obtaining out on pass from residents which allows the resident to go in and out of the facility up until the end time written on the out on pass document, for example till 6pm, 8pm, or 10pm. The security guard stated some residents hand in their cigarettes and lighters and some residents do not; responding to the security guard that they are grown. The security guard stated that the social worker was informed about this issue and spoke to the residents. On the ninth floor 3 residents (#155, #156, #228) were identified by the security guard as residents who refuse to hand in their cigarettes and lighters. On 11/20/18 at 2:45 PM at the security guard's desk, zip lock bags containing cigarette(s) (individual or boxed) and/or lighter(s) labeled with residents' names was observed. Resident #156 zip lock bag contained 2 lighters and 1 single cigarette and resident # 228 had two boxes of cigarettes, no lighter The security guard stated that he was just provided with a Smoking Material Log on 11/20/18 to use for the residents. There is no policy or procedure for that give instruction to security staff in regards to monitoring of return of residents who smoke and return from Out on Pass. The facility did not provide evidence of a mechanism in which security staff would be able to keep track of which residents was given lighted materials. On 11/20/18 at 02:50 PM, an interview was conducted with the Director of Social Services (DSS) who has worked at the facility since (MONTH) (YEAR). The DSS stated the role of social workers in smoking are counseling residents who smoke when there is a noncompliance issue with smoking. The DSS stated she was not informed that residents were not returning the lighters and/or cigarettes by staff including social workers. The DSS discussion with resident #156 resulted in him giving what he had, and a lighter was found in the room of resident #228. The DSS stated these residents go out on pass a lot and will be re-educated followed by signing the smoking contract. The Facility Smoking Contract for Residents dated 11/20/18 was signed by resident #156, and declined/refused by resident #228. On 11/20/18 at 02:58 PM, a telephone interview was conducted with the Recreation Director (Rec. Dir.) who has worked at the facility for 6 years. Rec. Dir. stated the department monitors, supervises smoking residents and conduct initial and quarterly assessments of resident deemed as smoking out on pass. The resident out on pass is supposed to return the lighting material to security. If there is an issue such as the lighting material not being returned by the resident, security would contact the unit Nurse Supervisor. Then other disciplines would be informed such as social services and recreation. The Rec. Dir. stated during quarterly assessments, security is asked about paraphernalia not being returned by residents who smoke while out on pass, to aid in the determination of quarterly smoking status. When smoking paraphernalia (including lighting material) is found with the resident, the resident gets a warning that includes re-education on facility smoking requirements. The resident is still considered a safe smoker. When found non-compliant for the second time, the resident would immediately be placed into the supervised smoking program and document in the resident's file. Rec. Dir. could not confirm that the actions above where contained in the smoking policy. The Rec Director could not verify that such actions were taken when lighted materials were found in the rooms of residents #156 and #228. A follow up interview was conducted on 11/20/18 at 03:50 PM with the NCC who stated that on 11/20/18, after surveyor interviews with residents and staff, a search of the rooms of the two residents who stated they were holding unto cigarettes and/or lighters were conducted by the DSS, NCC, CNA #2 and LPN #1. The search resulted in resident #156 initially denying having anything, but upon further questioning by DSS the resident gave a lighter and e-cigarette to staff. Resident #228 turned in their lighter to staff. The NCC stated that the facility does not generate an incident report, but will add these residents to the 24 hour report; nursing and social services will document in the residents' chart. On 11/21/18 at 11:11 AM, an interview was conducted with the Director of Nursing Services (DNS) who has worked at the facility for 1.5 years. The DNS supervises the Educator, NCCs, LPNs and CNAs through rounding, education, morning reports, annual competencies, monthly in-service nursing staff, 1199 and other outside agencies for education; recently training on PICO wound dressing and Neulesta as an alternative to psychiatric medications occurred. The DNS stated being informed at morning reports of any changes that occurred during the night, nursing issues with the patients, incidents, accidents; any room change, death, admission to the hospitals during the off shift and lab work related to isolation. DNS also stated conducting rounding at least once a day on 2 units observing dining, meds, CNA giving care, including agency staff. If an error is observed the DNS will educate followed by secondary observation usually within the week and based on the severity education would be provided right away by the Educator. On 11/20/18 the facility provided the results of a room search, conducted on the same day of residents identified as smokers who have Out on Pass privileges. The results revealed that no materials in 6 resident rooms and cigarettes/lighting materials were found in 8 resident rooms. After the search the facility developed and implemented The Smoking Material Log and provided to the security guard. 415.12(h)(1)

Plan of Correction: ApprovedJanuary 11, 2019

F 689- To ensure that each resident received adequate supervision and that the resident's environment remain free to prevent accident hazards, the facility must have a clear policy and procedures to prevent residents from storing lighting materials on the units.
Immediate Corrective Action
Resident #156
1. On 11/20/18 The Administrator, DON, and the Director of SW met with res# 156 and interviewed resident.Resident # 156 stated he will not keep any smoking materials with him. Room search was done of Res #156 with his approval and no smoking materials were found (cigarettes, lighters, matches).
2. Room searches are done every shift by CNA and documented on room search log for smoking paraphernalia.

3. On 11/20/18, res #156 was re-educated on the facility policy for smoking. The SW reviewed and the resident and the resident signed a new Smoking agreement. The resident demonstrated understanding that violations to the smoking policy would result in revocation of independent out on pass privileges.
4. The facility Out of Pass (OOP) policy was reviewed with the resident with emphasis placed on a search by security for smoking paraphernalia by Security.
5. The residents Comprehensive Care Plan (CCP) for Smoking and Resident Profile were updated to include the residents past noncompliance with hiding smoking paraphernalia.
6. The Director of Recreation updated the Facility list of all residents that smoke and distributed the list to all Departments, Security and Units.
7. Educational counseling will be issued to any staff member who does not immediately report residents that have smoking materials incl Security, CNa, LPN.

Res #228
1. On 11/20/18 The Administrator, DON, and the Director of SW met with res# 228 and interviewed resident.Resident # 156 stated he will not keep any smoking materials with him. Room search was done of Res #156 with his approval and no smoking materials were found (cigarettes, lighters, matches).
2. Room searches are done every shift by CNA and documented on room search log for smoking paraphernalia.

3. On 11/20/18, res #228 was re-educated on the facility policy for smoking. The SW reviewed and the resident and the resident signed a new Smoking agreement. The resident demonstrated understanding that violations to the smoking policy would result in revocation of independent out on pass privileges.
4. The facility Out of Pass (OOP) policy was reviewed with the resident with emphasis placed on a search by security for smoking paraphernalia by Security.
5. The residents Comprehensive Care Plan (CCP) for Smoking and Resident Profile were updated to include the residents past noncompliance with hiding smoking paraphernalia.
6. The Director of Recreation updated the Facility list of all residents that smoke and distributed the list to all Departments, Security and Units.
7. Educational counseling will be issued to any staff member who does not immediately report residents that have smoking materials incl Security, CNa, LPN.
II. Identification of other Residents
1. The facility respectfully states that all residents were potentially affected.
2. The Administrator obtained a list of all residents that smoke. This list was used by the Recreation Director to complete a Smoking Assessment and updated contract with each resident reassessed and the smoking contract signed.




III. Systematic Changes
1.On 11/19/2018 , the Administrator and DON reviewed the facility policy and procedure for smoking. The revised P/P will be in-serviced by the Director of In-service for all staff. The following revisions were made:
A. No one is no longer considered independent in smoking. All persons who smoke are supervised by the Recreation department. They will give all smokers 1-2 cigarettes during the smoking time and light it for them. The residents will not have access to the cigarettes or the lighters. All smoking materials will be kept in the locked smoking cart and dispensed by the recreation aide.
B. Social service will inform and invite all smokers to participate in a smoking cessation program
C. The outdoor patio is the only designated smoking area for residents, during the designated smoking times, 9:15 am, 1:15 pm, 4:30 pm, and 7 pm every day.
D. Resident's that previously had an Independent Out on Pass may no longer smoke while out on pass.
2.On 11/27/2018, the administrator and DON reviewed the facility policy and procedure for Out on Pass privileges (OOP). The revised P/P will be in-serviced by the In-service Director for all Nursing, SW, Activities and Security staff. The following revisions were made:
A. On 11/20/18, the administrator in conjunction with the DON will no longer issue OOP to smoke in the front of the building.
B. OOP has a four time frame.
3. At the monthly resident council meeting, with department heads present, residents were advised regarding the new facility policies for smoking and out on pass. They were also reminded that it is forbidden to possess any smoking material, and if violated, risk being discharged from the facility.
IV QA Monitoring
4. The Director of Recreation/Designee in conjunction with the Social Worker will conduct monthly smoking/out on pass audits, of the residents who smoke to ensure they remain in compliance of the smoking and out on pass policy,and will also include the recreation department disbursement and retrieval of the smoking material.
5. The Director of Recreation/Designee will review the findings of the monthly smoking/out on pass audits, and present findings to the QA Committee on a monthly basis, for evaluation by the QA committee.
6. Any smoking/out on pass audits that have any negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.

V Responsible Person
All corrective actions will be completed by the Administrator by 1/20/2019.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews, during the Recertification survey, the facility did not ensure that a resident receive treatment and care in accordance with professional standard and resident's choice. Specifically, a change in the resident's skin condition (skin growth) was not identified by competent nursing staff and a nurse practitioner. This was evident for 1 out of total investigation sample of 36 residents (Resident # 89). The facility's policy and procedure Policy for Skin Care reviewed (MONTH) (YEAR) documented that each resident has systemic skin assessment and care consisting of inspection, cleansing, hydration, and protection. The facility's procedure includes evaluate for integrity, color, temperature, and turgor. Reassess the skin at regular intervals as determined by the resident's level of risk. Ongoing assessment can be done during bathing, changing, or exercise. The findings are: Resident #89 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] documented the resident as cognitively intact requiring supervision with setup only for bed mobility, transfers and eating and total dependence with one person physical assist for toilet use. The resident has a catheter and bowel is always incontinent. On 11/14/18 at 01:24 PM during an interview the resident stated wanting to see a Dermatologist for a 2-3-month-old skin growth behind the right ear. The resident stated a nurse reviewed the area and said it was nothing and will go away. No care plan related to skin growth behind the ear and treatment was found. On the care plan initiated 12/21/17 documented at risk for skin breakdown (at risk for skin breakdown related to Braden scale score, decreased mobility, incontinence, [MEDICAL CONDITIONS] or malnourishment documented the goal as the resident will maintain intact skin through interventions such as administer vitamins/supplements as ordered; complete pressure ulcer risk assessment (Braden Scale) and review quarterly and PRN; provide pressure reducing mattress, and use pressure reducing cushion when in wheelchair. There is no care plan related to skin growth or treatment behind the ear. On 11/20/18 at 12:11 PM, an interview was conducted with Certified Nurse Assistant (CNA #1) who has worked [AGE] years at the facility. CNA #1 stated residents are rotated every 3 months amongst CNAs and has been assigned to the resident since (MONTH) (YEAR). CNA #1 conducts skin checks every day and during showers, observing for red marks or bruises, but did not see any moles or growth behind the resident's ear. CNA #1 stated training on skin checks included looking for skin discoloration, scratches, and bruises. As per CNA #1, the resident has not complained about any pain but when the resident is quiet something may be wrong and will follow up with the resident and inform the nurse. On 11/20/18 at 12:21 PM, an interview was conducted with Licensed Practical Nurse (LPN #1) who has worked on the unit for six months. LPN #1 conducts body checks every two weeks to determine any unusual change in skin, any opening or rashes. LPN #1 stated the skin growth behind the right ear of the resident was observed six months ago, and at that time the resident was asked and replied that it was taken care of. LPN #1 could not recall if Nursing was informed about the skin and stated the skin growth is the same color and size about 2cm by 2 cm. LPN #1 also stated the resident did not complain about any pain. On 11/20/18 at 12:33 PM the Nursing Care Coordinator (NCC) was interviewed, whose supervisory role includes managing two units, conducting daily rounds on each floor and residents' rooms, notifying residents' family members of any changes, periodically observe wound rounds and communicating with the Nurse Practitioner (NP). The NCC also stated that she relies on Charge Nurses (2 LPNs per floor) to supervise staff and inform the NCC of any issues on the floor. The NCC stated not being aware or notified of the skin growth behind the resident's ear. As per the NCC, the resident stated the skin growth has been there for a few years and that the resident had spoken to staff about his concerns, but staff does not remember and the LPNs stated they did not see the skin growth. On 11/20/18 at 03:18 PM an interview was conducted with the NP who stated being employed at the facility for approximately two years and working about six months with the resident. The NP conducts monthly physical examinations of residents assessing for excoriation, rashes; is also alerted by Nurses/CNA, and asks the residents if there are any issues. The NP stated that the resident was seen in (MONTH) (YEAR) but the skin growth was not observed. In addition, the NP stated that other staff did not observe the skin growth, during wound care, Dermatology consults, including the resident did not bring it to her attention. The NP stated being alerted today about the skin growth followed by seeing the resident and scheduling a Dermatology consult. When asked, the NP replied that the location of the growth was not an area of the skin that was physically examined. On 11/20/18 at 03:50 PM during the follow up interview, the NCC confirmed that there was no Care Plan which identified the growth behind the resident's ear, and as such there was no plan in place for monitoring that area of the skin, or an interventions to treat. There was also no plan for the resident to be examined by a dermatologist or other medical personnel. On 11/20/18 at 04:45 PM an interview was conducted with the Medical Director (MD) who has worked at the facility for about [AGE] years. The MD stated his role includes providing support to staff related to medical issues, reviewing new admissions and discharge of all resident transfers. The MD stated he does not provide direct care to residents and that this resident does not sound familiar. Progress notes dated 11/20/18, (during the survey) by NP documented pt seen and evaluated for skin growth notes behind right ear no crusting no bleeding asymmetrical with smooth even borders notes appears to be all one color and is approx. 2 cm in diameter no c/o pain or discomfort at this time pt needs dermatology consult for further evaluation will add urgent eval and cont to monitor pt stable. Progress notes by NCC dated 11/20/18 documented that the resident was seen and evaluated for skin growth notes behind right ear no crusting no bleeding asymmetrical with smooth even borders notes appears to be all one color and is approx. 2 cm in diameter no c/o pain or discomfort at this time pt needs dermatology consult for further evaluation will add urgent eval and cont to monitor pt stable, at this time no treatment was ordered and the color of the growth is purple colored. Will continue plan of care. 415.12

Plan of Correction: ApprovedJanuary 2, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. On 11/20/18 res #89 was physically assessed by the Primary Medical Doctor/Nurse Practitioner and was noted to have a [MEDICAL CONDITION] behind the right ear, and a Dermatology consult was recommended.
2. On 11/20/18 the res #89 and his family were made aware of the findings. The Interdisciplinary Team reviewed and revised the Comprehensive
Care Plan of res #89 to reflect the updated plan of care.
3. On 11/20/18 the Director of In service Education conducted an educational
Counseling with LPN #1 and the CNA for not reporting the [MEDICAL CONDITION] to the Nurse Clinical Coordinator or Nurse Practitioner.
4. On 11/29/18 res # 89 was seen and examined by the Dermatologist and
recommendation was to be followed up in his office for biopsy and removal of
[MEDICAL CONDITION].
5. On 12/13/18 res # 89 seen at Dermatologist office biopsy of [MEDICAL CONDITION] done, removal of tissue. Treatment ordered, dry dressing daily for seven days and completed. Biopsy is benign.
II. Identification of Other Residents
1. On 12/17/18 the Director of Nursing in conjunction with the Director of In service Education obtained a list of all residents in the facility.
2. The DON in conjunction with the Nurse Clinical Coordinator assigned to each unit will conduct body inspection on each unit to ensure no skin impairments, [MEDICAL CONDITION] in accordance with professional standards and resident choices.
3. No other resident has been found to be affected.

III. Systematic Changes
1. On 12/18/18 the Medical Director in conjunction with the Director of Nursing
reviewed the facility Policy/ Procedure for Skin Care and no changes were made.
2. Director of In-service Education/Designee are conducting education and counseling to all licensed nursing staff and certified nursing assistants deficient in this practice, of immediately reporting any changes in residents skin condition to the Nurse Clinical Coordinator and/or Primary Care Physician.

IV. QA Monitoring
3. Using a skin audit QA tool, the DON/ Designee will conduct weekly audits for twelve weeks, then every three months thereafter.
4. The Director of Nursing/Designee will quarterly review the audits quantitative finding and summarize for compliance and present findings to the QAPI committee on a quarterly basis, and for re-evaluation by the QA committee on a going basis.
5. Any skin audits that reveal a negative outcome will immediately reported to the
Director of Nursing and the Administrator for further action.
V. Responsible Person
All corrective actions will be completed by the Director of Nursing/Director of Staff Education by 1/20/2019.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

2012 NFPA 101 19.1.6 Minimum Construction Requirements. 19.1.6.1 Health care occupancies shall be limited to the building construction types specified in Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7. (See 8.2.1.) 8.2 Construction and Compartmentation. 8.2.1 Construction. 8.2.1.1 Buildings or structures occupied or used in accordance with the individual occupancy chapters, Chapters 11 through 43, shall meet the minimum construction requirements of those chapters. 8.2.1.2* NFPA 220, Standard on Types of Building Construction, shall be used to determine the requirements for the construction classification. 2012 NFPA 220 4.3.1 Type I and Type II Construction. Type I (442 or 332) and Type II (222, 111, or 000) construction shall be those types in which the fire walls, structural elements, walls, arches, floors, and roofs are of approved noncombustible or limited combustible materials. (5000:7.2.3.1) 4.1.5 Noncombustible Material. 4.1.5.1* Amaterial that complies with any one of the following shall be considered a noncombustible material: (1)*The material, in the form in which it is used, and under the conditions anticipated, will not ignite, burn, support combustion, or release flammable vapors when subjected to fire or heat. (2) The material is reported as passing ASTM E 136, Standard Test Method for Behavior of Materials in a Vertical Tube Furnace at 750 Degrees C. (3) The material is reported as complying with the pass/fail criteria Of ASTM E 136 when tested in accordance with the test method and procedure in ASTM E 2652, Standard Test Method for Behavior of Materials in a Tube Furnace with a Coneshaped Airflow Stabilizer, at 750 Degrees a limited-combustible material where both of the following conditions of 4.1.6.1 and 4.1.6.2, and the conditions of either 4.1.6.3 or 4.1.6.4 are met. (5000:7.1.4.2) 4.1.6.1 The material does not comply with the requirements for a noncombustible material, in accordance with 4.1.5. (5000:7.1.4.2(1)) 4.1.6.2 The material, in the form in which it is used, exhibits a potential heat value not exceeding 3500 Btu/lb (8141 kJ/kg), when tested in accordance with NFPA 259, Standard Test Method for Potential Heat of Building Materials. (5000:7.1.4.2(2)) 4.1.6.3 The material shall have a structural base of a noncombustible material with a surfacing not exceeding a thickness of 1?8 in. (3.2mm )where the surfacing exhibits a flame spread index not greater than 50 when tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials. (5000:7.1.4.2.1) Based on observation and staff interview during the recertification survey, the facility did not ensure that the building was maintained as Type I or II construction required for high rise health care occupancies. This occurred in the rooftop elevator machine room. The findings include: During the life safety portion of the recertification survey on 11/14/2018 at approximately 10:10 am, unprotected steel beams were noted at the ceiling of the rooftop elevator machine room. All the steel roof beams in this room were lacking fire resistant rated spray in areas ranging from six by four inches to twelve by four inches, in multiple locations along each beam. Upon interview concurrent with these findings, the Maintenance Director stated that the beams would be resprayed. 2012 NFPA 101 2012 NFPA 220 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedDecember 5, 2018

K 161 - BUILDING CONSTRUCTION- UNPROTECTED STEEL BEAMS
I. Immediate Corrective Action
1. The facility contacted an approved Fire Protection applicator to repair/replace the damaged fire protection on the unprotected steel beams which were noted at the ceiling of the rooftop elevator machine room.
II. Identification of other Residents
1. No individual residents were found to be affected by the deficient practice. The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
2. The Director of Environmental Services inspected all other openings for complete closure and found none to be out of compliance.
3. No additional quality issues were identified.
III. Systematic Changes
1. The facility has updated policies about repair and construction to include complete closure of any openings upon completion of work.
2. The facility policy for work was reviewed and amended to include replacement of fire protection items upon completion of repairs.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct quarterly audits.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not comply with Federal, State and local laws. The contact information in the Health Provider Network (HPN) Communications Directory was not current and updated timely. The findings are: On 11/16/18 between 11:00am- 2:30pm during the recertification survey, review of the facility's Communications Directory on the HPN revealed that the contact information for the roles under the twenty four hour, seven days a week facility contact, Director of Nursing, and the Office of the Administrator was not current and updated timely. The last update was April, (YEAR). The role of Coordinator, MDS was last updated in 2011. Additionally, the role of the Emergency Medical Supplies Receiving Office, Fiscal Office, Designated Pharmacist, Director of Patient and family Services, and many others were unassigned. This was contrary to the requirements of 10NYCRR 400.10 in that current and complete updates of the Communications Directory reflecting changes that include, but are not limited to, general information and personnel role changes as soon as they occur, and at a minimum, are completed on a monthly basis. In an interview on 11/16/18 at approximately 3:00 pm, the Assistant Administrator stated that they will update the contact information. 10NYCRR 400.10

Plan of Correction: ApprovedDecember 5, 2018

E029 - HPN
I. Immediate Corrective Action
1. The administrator has reviewed with Žthe emergency management team to update and develop the provisions for proper communication section of the Comprehensive Emergency Preparedness Plan.
3. The Administrator will develop a Comprehensive Emergency Preparedness Plan, which utilizes and all hazards approach. The plan will include policy and procedures for a process regarding the communication, interaction and coordination of care with other health care providers and State Agencies including the updating of critical contacts on the HCS and HERDS systems.
II. Identification of Other Residents
The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
III. Systemic Changes
1. The Administrator, in conjunction with the Director of Maintenance, Director of Nursing and Medical Director, reviewed and revised the facility emergency policies and procedures and incorporated the process regarding the communication, interaction and coordination of care with other health care providers and State Agencies during an emergency into the Comprehensive Emergency Preparedness Plan.
2. The Administrator or his/her designee shall be assigned to update the NYSDOH information systems upon any change in personnel.
3. The Director of Inservice Education will In-service facility staff on the facility Emergency Preparedness Plan, including the facility communication plans.
4. Attendance Records will be maintained for reference and validation.
IV. QA Monitoring
1. The Administrator, in conjunction with the Director of Maintenance and Inservice coordinator, will conduct Emergency Preparedness Drills and/or Table Top exercises with facility staff for the next 3 months, then bi-annually thereafter. Documentation of drill and critiques of staff performance will be maintained in logbook for reference and validation.
2. The Director of Maintenance will review the staff response to Emergency Preparedness Drills and Tabletop exercises, including the tracking if staff component of plan, and present findings to the QA Committee on a monthly basis, for evaluation by the QA Committee.
3. Drill response that reveals negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.
V. All corrective actions will be completed by the Administrator by 1/20/2019

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

2012 NFPA .2.2.2 Doors. 19.2.2.2.1 Doors complying with 7.2.1 shall be permitted. 19.2.2.2.2 Locks shall not be permitted on patient sleeping room doors, unless otherwise permitted by one of the following: (1) Key-locking devices that restrict access to the room from the corridor and that are operable only by staff from the corridor side shall be permitted, provided that such devices do not restrict egress from the room. (2) Locks complying with 19.2.2.2.5 shall be permitted. 19.2.2.2.3 Doors not located in a required means of egress shall be permitted to be subject to locking. 19.2.2.2.4 Doors within a required means of egress shall not be equipped with a latch or lock that requires the use of a tool or key from the egress side, unless otherwise permitted by one of the following: (1) Locks complying with 19.2.2.2.5 shall be permitted. (2)*Delayed-egress locks complying with 7.2.1.6.1 shall be permitted 7.2.1.6.1 Delayed-Egress Locking Systems. 7.2.1.6.1.1 Approved, listed, delayed-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler system in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (1) The door leaves shall unlock in the direction of egress upon actuation of one of the following: (a) Approved, supervised automatic sprinkler system in accordance with Section 9.7 (b) Not more than one heat detector of an approved, supervised automatic fire detection system in accordance with Section 9.6 (c) Not more than two smoke detectors of an approved, supervised automatic fire detection system in accordance with Section 9.6 (2) The door leaves shall unlock in the direction of egress upon loss of power controlling the lock or locking mechanism. (3)*An irreversible process shall release the lock in the direction of egress within 15 seconds, or 30 seconds where approved by the authority having jurisdiction, upon application of a force to the release device required in 7.2.1.5.10 under all of the following conditions: (a) The force shall not be required to exceed 15 lbf (67 N). (b) The force shall not be required to be continuously applied for more than 3 seconds. (c) The initiation of the release process shall activate an audible signal in the vicinity of the door opening. (d) Once the lock has been released by the application of force to the releasing device, relocking shall be by manual means only. (4)*A readily visible, durable sign in letters not less than 1 in. (25 mm) high and not less than 1?8 in. (3.2 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTILALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS (5) The egress side of doors equipped with delayed-egress locks shall be provided with emergency lighting in accordance with Section 7.9. The requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that delayed egress doors at the stairwells were maintained so as to alarm when the door was opened and/or to open after fifteen seconds as stated on the door signs. This occurred on nine out of nine floors. The findings include: During the life safety portion of the recertification survey on 11/14/2018, the following stairwell delayed egress doors were found not to open after normal force was applied for fifteen second as stated on the door sign: 1)Stairwell A on the 9th floor. 2)Stairwell B on the 8th floor. 3)Stairwell B on the 7th floor. 4)Stairwell B on the 6th floor. 5)Stairwell B on the 5th floor. 6)Stairwell B on the 4th floor. 7)Stairwell B on the 3rd floor. 8)Stairwells B and A on the 2nd floor. 9)Stairwell A on the 1st floor. In addition, the delayed egress doors at stairwell B on the 4th floor and 6th floor did not alarm when opened. Upon interview concurrent with these findings, the Maintenance Director stated that all fire doors in the facility are inspected quarterly, and that he suspected the door controls may have been altered when work was done on the telephone system. He further stated that all doors would be adjusted so that they open after fifteen seconds, and the alarm at each door activates. 2012 NFPA 101 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedDecember 5, 2018

K 222 - DOOR EGRESS
I. Immediate Corrective Actions
1. The Facility contacted the alarm service company to correct the inoperative release of delayed egress doors and repair the non-sounding alarms.
2. The following stairwell delayed egress doors were made to open after normal force was applied for fifteen second as stated on the door sign:
1)Stairwell A on the 9th floor.
2)Stairwell B on the 8th floor.
3)Stairwell B on the 7th floor.
4)Stairwell B on the 6th floor.
5)Stairwell B on the 5th floor.
6)Stairwell B on the 4th floor.
7)Stairwell B on the 3rd floor.
8)Stairwells B and A on the 2nd floor.
9)Stairwell A on the 1st floor.
The delayed egress doors at stairwell B on the 4th floor and 6th floor did alarm
when opened.
II. Identification of other Residents
1. The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
2. The Director of Environmental Services inspected all other egress doors and found them to be in reliable operating condition.
III. Systematic Changes
1. The facility policy on delayed egress was reviewed and updated to increase the inspection and testing interval from quarterly to monthly.
2. The facility will perform inservice to staff on the updated policy to staff performing the preventive maintenance.
IV. Q/A Monitoring
1. The Director of Environmental Services will review monthly audits over the next year.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

K307 NFPA 101:ELECTRICAL EQUIPMENT - OTHER

REGULATION: Electrical Equipment - Other List in the REMARKS section any NFPA 99 Chapter 10, Electrical Equipment, requirements that are not addressed by the provided K-Tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567. Chapter 10 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

2012 NFPA 101 19.5 Building Services. 19.5.1 Utilities. 19.5.1.1 Utilities shall comply with the provisions of Section 9.1. 2012 NFPA 101 9.1.2 Electrical Systems. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. 2011 NFPA 70 210.8 B. Other Than Dwelling Units. All 125-volt, singlephase, 15- and 20-ampere receptacles installed in the locations specified in 210.8(B)(1) through (8) shall have ground-fault circuit-interrupter protection for personnel. (1) Bathrooms (2) Kitchens (3) Rooftops (4) Outdoors Exception No. 1 to (3) and (4): Receptacles that are not readily accessible and are supplied by a branch circuit dedicated to electric snow-melting, deicing, or pipeline and vessel heating equipment shall be permitted to be installed in accordance with 426.28 or 427.22, as applicable. Exception No. 2 to (4): In industrial establishments only, where the conditions of maintenance and supervision ensure that only qualified personnel are involved, an assured equipment grounding conductor program as specified in 590.6(B)(2) shall be permitted for only those receptacle outlets used to supply equipment that would create a greater hazard if power is interrupted or having a design that is not compatible with GFCI protection. (5) Sinks - where receptacles are installed within 1.8 m (6 ft) of the outside edge of the sink. Based on observation and staff interview during the recertification survey, the facility did not install and maintain all electrical receptacles in accordance with 2011 NFPA 70. This occurred on nine out of nine floors of the building. The findings include: During the life safety portion of the recertification survey on 11/14/2018 between the hours of 9:30am and 3:00pm, the soiled utility rooms on each of the nine floors of the facility were noted to have electrical receptacles within six feet of the sink lacking ground fault circuit interrupter (GFCI) protection. Upon interview, concurrent with these findings, the Maintenance Director stated that the receptacles in each soiled utility room would be replaced. 2012 NFPA 101 2011 NFPA 70 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedDecember 5, 2018

K 919
I. Immediate Corrective Action
1. The facility maintains a policy of compliance with NFPA 70, Electrical wiring and equipment
shall be in accordance with NFPA 70, National Electrical Code, unless such installations are approved existing installations, which shall be permitted to be continued in service. The preexisting soiled utility rooms on each of the nine floors of the facility were noted to have electrical receptacles within six feet of the sink lacking ground fault circuit interrupter (GFCI) protection. Although the code does permit this situation the facility has replaced the outlets with GFCI type.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
1. The facility electrician has conducted a review of all other areas which could be affected and determined that no areas were in in need of updating.
III. Systemic changes
1. The facility shall conduct a review of changes and updates in the electric code to determine if further action on other areas of the code could be implemented and scheduled.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct audits over the next quarter to determine what areas of the electric system would benefit from updating and present them to administration for future facility improvement.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

2012 NFPA 99 15.5.1.3 Emergency Generators and Standby Power Systems. Emergency generators and standby power systems, where required for compliance with this code, shall be installed, tested , and maintained in accordance with NFPA 110, Standard for Emergency and Standby Power Systems. 2010 NFPA 110 8.3.8 A fuel quality test shall be performed at least annually 8.4.9* Level 1 EPSS shall be tested at least once within every 36 months. 8.4.9.1 Level 1 EPSS shall be tested continuously for the duration of its assigned class (see Section 4.2). 8.4.9.2 Where the assigned class is greater than 4 hours, it shall be permitted to terminate the test after 4 continuous hours. 8.4.9.3 The test shall be initiated by operating at least one transfer switch test function and then by operating the test function of all remaining ATSs, or initiated by opening all switches or breakers supplying normal power to all ATSs that are part of the EPSS being tested . 8.4.9.4 A power interruption to non-EPSS loads shall not be required. 8.4.9.5 The minimum load for this test shall be as specified in 8.4.9.5.1, 8.4.9.5.2, or 8.4.9.5.3. 8.4.9.5.1 For a diesel-powered EPS, loading shall be not less than 30 percent of the nameplate kW rating of the EPSA Supplemental load bank shall be permitted to be used to meet or exceed the 30 percent requirement. 8.4.9.5.2 For a diesel-powered EPS, loading shall be that which maintains the minimum exhaust gas temperatures as recommended by the manufacturer. 8.4.9.5.3 For spark-ignited EPSs, loading shall be the available EPSS load. 8.4.9.6 The test required in 8.4.9 shall be permitted to be combined with one of the monthly tests required by 8.4.2 and one of the annual tests required by 8.4.2.3 as a single test. 8.4.9.7 Where the test required in 8.4.9 is combined with the annual load bank test, the first 3 hours shall be at not less than the minimum loading required by 8.4.9.5 and the remaining hour shall be at not less than 75 percent of the nameplate kW rating of the EPS. The requirement is not met as evidenced by: Based on document review and staff interview during the recertification survey, the facility did not ensure that the generator was tested and maintained in accordance with the requirements of NFPA 110. The findings include: During the life safety portion of the recertification survey on 11/15/2018 between 11:30 am and 1:30 pm, it was noted that the facility was not conducting the following tests on its two emergency generators: 1)Annual fuel test. 2)The 36- month four-hour load test. Upon interview, on 11/16/2018 during the exit conference at approximately 2:45 pm, the Maintenance director stated that all required tests would be performed. 2012 NFPA 99 2010 NFPA 110 10 NYCRR 711.2(a)

Plan of Correction: ApprovedDecember 5, 2018

K 918 ? GENERATOR TESTING
I. Immediate corrective action
1. The facility contacted the Generator service company to conduct the following tests on its two emergency generators:
1)Annual fuel test.
2)The 36- month four-hour load test.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
No other inspection/ maintenance requirements were missed.
III. Systematic changes
1. The facility shall provide information to the generator company regarding the requirements for generator testing.
2. Staff involved in generator operation and maintenance will be in-serviced on the requirements of generator testing.
3. The PM system shall be updated to include the required maintenance items missed.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5 foot candles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20°F (-6.7°C), or b. The outside design temperature is lower than +20°F (-6.7°C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. 1999 NFPA 99: 3-5.2.2.4 Wiring Requirements. (a) * Separation from Other Circuits. The emergency system shall be kept entirely independent of all other wiring and equipment. (b) * Receptacles. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. Based on observation, document review (i.e., posted electrical panel directories), and staff interview, the facility was not able to demonstrate that it was provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System, in that Emergency System- Life Safety Branch wiring was not separated from Critical System wiring, required for a facility housing a ventilator unit. This facility has a vent unit on the eighth floor. The findings are: 1)During the life safety portion of the recertification survey on 11/14/2018 between the hours of 9:30 am and 3 pm, it was noted that all the electrical panels on each floor of the building lacked labels identifying the loads served by the panels. Specifically, there was no indication which circuit panels served the life safety branch and critical branches of the essential electrical system. 2)The following circuit panels were missing panel directories: a)One of the three unlabeled panels near the service elevator on the eighth floor. b)One of the three unlabeled panels near the service elevator on the fifth floor. c)One of the three unlabeled panels near the service elevator on the 2nd floor. 3)The following circuit panel directories indicated that the panels served both life safety and critical or other loads: a)The directories for an unlabeled circuit panels on the 9th floor listed hall lights, hall receptacles, machine room, clean utility lights, nurses' station and nurse call. b)The directories for the unlabeled circuit panels on the 8th and 7th floor listed dining room lights, water cooler, numerous receptacles, refrigerator and ice machine, and nurses' station, and unspecified lights. c)The directories for the unlabeled circuit panels on the 6th floor listed hall emergency lights, med room light, and resident room air conditioning units. d)The directories for the unlabeled circuit panels on the 5th floor listed dining room lights, numerous receptacles and unspecified lights. e)The directories for the unlabeled circuit panels on the 4th and 3rd floor listed hall lights, soiled utility lights and receptacles, and numerous other unspecified lights and receptacles. f)A panel directory on the second floor listed hall lights, dining room lights, nurse call and receptacles. Upon interview concurrent with these findings on 11/14/18, the Maintenance Director stated that the facility was fully powered by two generators and two transfer switches, and that new electrical panels had been installed on several floors. He further stated that after the automatic transfer switches, the life safety branch wiring was not separated from critical and other wiring.

Plan of Correction: ApprovedDecember 5, 2018

K 915 - ELECTRICAL SYSTEMS- LIFE SAFETY
I. Immediate corrective Action
The facility has had the emergency electrical system updated by a licensed electrician in accordance NFPA 70 and all local codes. The system was installed as by a licensed electrician.
The electrician has been contacted and is scheduled to review the installation for compliance with NFPA 99.
The findings from the electrician will be reviewed with the QA committee and submitted to ownership for compliance.
1. All the electrical panels on each floor of the building lacked labels identifying the loads served by the panels. The mislabeled panels were corrected by the electrician
2. The indication which circuit panels served the life safety branch and critical branches of the essential electrical system was installed
3. The following circuit panels were missing panel directories:
a) One of the three unlabeled panels near the service elevator on the eighth floor.
b) One of the three unlabeled panels near the service elevator on the fifth floor.
c) One of the three unlabeled panels near the service elevator on the 2nd floor.
4. The facility shall have a licensed electrician separate the Life Safety branch wiring. All critical and life safety panels will be inspected for proper items and have panels labeled correctly.
The following circuit panel directories indicated that the panels served both life safety and critical or other loads:
a) The directories for an unlabeled circuit panels on the 9th floor listed hall lights, hall receptacles, machine room, clean utility lights, nurses' station and nurse call.
b) The directories for the unlabeled circuit panels on the 8th and 7th floor listed dining room lights, water cooler, numerous receptacles, refrigerator and ice machine, and nurses' station, and unspecified lights.
c) The directories for the unlabeled circuit panels on the 6th floor listed hall emergency lights, med room light, and resident room air conditioning units.
d) The directories for the unlabeled circuit panels on the 5th floor listed dining room lights, numerous receptacles and unspecified lights.
e) The directories for the unlabeled circuit panels on the 4th and 3rd floor listed hall lights, soiled utility lights and receptacles, and numerous other unspecified lights and receptacles.
F) A panel directory on the second floor listed hall lights, dining room lights, nurse call and receptacles.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
No other inspection requirements were missed.
III. Systematic Changes
1. The electrical distribution system will be monitored on a monthly basis by the electrician or his designee to ensure all required labeling is present and up to date.
2. Any added items will be updated on the charts and this will be added to any contract electrical work required.
3. all electrical work shall specified by licensed individuals so as to comply with all Federal, State and local codes prior to installation.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA .3.2.4 Medical Gas. Medical gas storage and administration areas shall be in accordance with Section 8.7 and the provisions of NFPA 99, Health Care Facilities Code, applicable to administration, maintenance, and testing. 2012 NFPA 99 11.3 Cylinder and Container Storage Requirements. 11.3.1* Storage for nonflammable gases equal to or greater than 85 m3 (3000 ft3) at STP shall comply with 5.1.3.3.2 and 5.1.3.3.3. 11.3.2* Storage for nonflammable gases greater than 8.5 m3 (300 ft3), but less than 85 m3 (3000 ft3), at STP shall comply with the requirements in 11.3.2.1 through 11.3.2.3. 11.3.2.1 Storage locations shall be outdoors in an enclosure or within an enclosed interior space of noncombustible or limitedcombustible construction, with doors (or gates outdoors) that can be secured against unauthorized entry. 11.3.2.2 Oxidizing gases, such as oxygen and [MEDICATION NAME] oxide, shall not be stored with any flammable gas, liquid, or vapor. 11.3.2.3 Oxidizing gases such as oxygen and [MEDICATION NAME] oxide shall be separated from combustibles or materials by one of the following: (1) Minimum distance of 6.1 m (20 ft) (2) Minimum distance of 1.5 m (5 ft) if the entire storage location is protected by an automatic sprinkler system designed in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems (3) Enclosed cabinet of noncombustible construction having a minimum fire protection rating of 1?2 hour 11.3.2.4 Gas cylinder and cryogenic liquid container storage shall comply with 5.1.3.5.12. 11.3.2.5 Cylinder and container storage locations shall comply with 5.1.3.3.1.7 with respect to temperature limitations. 11.3.2.6 Cylinder or container restraints shall comply with 11.6.2.3. 11.3.2.7 Smoking, open flames, electric heating elements, and other sources of ignition shall be prohibited within storage locations and within 6.1 m (20 ft) of outside storage locations. 11.3.2.8 Cylinder valve protection caps shall comply with 11.6.2.3. 11.3.2.9 Gas cylinder and liquefied gas container storage shall comply with 5.1.3.5.12. 11.3.3 Storage for nonflammable gases with a total volume equal to or less than 8.5 m3 (300 ft3) shall comply with the requirements in 11.3.3.1 and 11.3.3.2. 11.3.3.1 Individual cylinder storage associated with patient care areas, not to exceed 2100 m2 (22,500 ft2) of floor area, shall not be required to be stored in enclosures. 11.3.3.2 Precautions in handling cylinders specified in 11.3.3.1 shall be in accordance with 11.6.2. 11.3.3.3 When small-size (A, B, D, or E) cylinders are in use, they shall be attached to a cylinder stand or to medical equipment designed to receive and hold compressed gas cylinders. 11.3.3.4 Individual small-size (A, B, D, or E) cylinders available for immediate use in patient care areas shall not be considered to be in storage. 11.3.3.5 Cylinders shall not be chained to portable or movable apparatus such as beds and oxygen tents. 11.3.4 Signs. 11.3.4.1 A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 11.6.5 Special Precautions - Storage of Cylinders and Containers. 11.6.5.1 Storage shall be planned so that cylinders can be used in the order in which they are received from the supplier. 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. 11.6.5.2.1 When the facility employs cylinders with integral pressure gauge, it shall establish the threshold pressure at which a cylinder is considered empty. 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner. The requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not provide signage on the doors to oxygen storage areas compliant with NFPA 99 standards and did not ensure separation of full and empty oxygen cylinders stored within the room. This occurred on eight out of nine floors. The findings include: During the life safety portion of the recertification survey on 11/14/2018, between the hours of 9:30 am and 3:00pm, the following were noted 1)The oxygen storage closets on floors two through nine of the building did not have correctly worded identifying signage. Specifically, the signs did not state Caution: Oxidizing Gases Stored Within. No Smoking. 2)The carts used for storing both full and empty oxygen cylinders were not labelled to indicate which cart contained full cylinders and which contained empty. Upon interview concurrent with these findings, the Maintenance Director stated that new signs would be installed. 2012 NFPA 101 2012 NFPA 99 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedDecember 5, 2018

K 923 - OXYGEN SIGN
I. Immediate Corrective Action
1. The facility Engineer made signs complying with NFPA 99 11.3.4.2
CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING
signs were posted on all storage rooms.
2. The storage carts and areas were labeled for full and empty tanks.
3. staff followed NFPA 99 11.6.5.3 Empty cylinders shall be marked to avoid confusion and delay if a full cylinder is needed in a rapid manner.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
The engineer reviewed all oxygen storage and use areas for proper signage and storage conditions no other areas were found non-compliant.
III. Systematic changes.
1. The facility reviewed and updated the oxygen storage and use policy and procedure to comply with the requirements set forth in NFPA 99.
2. All staff shall be in-serviced on the requirements set forth in NFPA 99 for the storage and use of oxygen and the updates to the facility policy and procedure.
IV. Q/A Monitoring
1. The Director of Housekeeping Services will conduct weekly audits over the next quarter to determine if compliance with P & P is ongoing and report to administration for future facility improvement.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Housekeeping Services by 1/20/2019

POLICIES/PROCEDURES FOR SHELTERING IN PLACE

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:] [(4) or (2),(3),(5),(6)] A means to shelter in place for patients, staff, and volunteers who remain in the [facility]. *[For Inpatient Hospices at §418.113(b):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (i) A means to shelter in place for patients, hospice employees who remain in the hospice.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the sheltering in place of residents, staff and volunteers who remain in the facility during an emergency or disaster event. The facility lacked a policy regarding sheltering in place. The findings are: On 11/16/18 between 12pm- 2:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the sheltering in place of residents, staff and volunteers who will remain in the facility during an emergency. Facilities are required to have policies and procedures for sheltering in place which align with the facility's risk assessment and are expected to include the criteria for determining which patients and staff would be sheltered in place. In an interview on 11/16/18 at approximately 2:55 pm, the Assistant Administrator stated that they will update and revise the policies and procedures.

Plan of Correction: ApprovedDecember 5, 2018

E022 ? POLICIES & PR(NAME)EDURES FOR SHELTER IN PLACE
I. Immediate Corrective Action
1. The Administrator has reviewed with Žthe emergency management team to update and develop the shelter in place section of the Comprehensive Emergency Preparedness Plan.
2. The Administrator has developed a Comprehensive Emergency Preparedness Plan, which utilizes and all hazards approach. The plan will include policy and procedures for sheltering residents, staff and volunteers who remain in facility during an emergency or disaster event.
II. Identification of Other Residents
The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
III. Systemic Changes
1. The Administrator, in conjunction with the Director of Maintenance, Director of Nursing and Medical Director, reviewed and revised the facility emergency policies and procedures and incorporated the sheltering of resident, staff and volunteers in facility during an emergency into the Comprehensive Emergency Preparedness Plan.
2. The Director of Inservice Education will inservice all facility staff on the facility Emergency Preparedness Plan, including the facility procedures for sheltering of resident, staff and volunteers inside the facility during an emergency.
3. Attendance Records will be maintained for reference and validation.
IV. QA Monitoring
1. The Administrator, in conjunction with the Director of Maintenance and Inservice coordinator, will conduct Emergency Preparedness Drills and/or Table Top exercises with facility staff for the next 3 months, then bi-annually thereafter. Documentation of drill and critiques of staff performance will be maintained in logbook for reference and validation.
2. The Director of Maintenance will review the staff response to Emergency Preparedness Drills and Tabletop exercises, including the tracking if staff component of plan, and present findings to the QA Committee on a monthly basis, for evaluation by the QA Committee.
3. Drill response that reveals negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.
V. All corrective actions will be completed by the Administrator by 1/20/2019

ROLES UNDER A WAIVER DECLARED BY SECRETARY

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:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address the role of the facility under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site identified by emergency management officials. The facility lacked a policy for the provision of care and treatment at an alternate care site. The findings are: On 11/16/18 between 12:00pm- 2:00pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that they lacked a policy regarding the role of the facility under a waiver declared by the Secretary in the provision of care and treatment at an alternate care site identified by emergency management officials. The provided policy and procedure only gave an overview of the 1135 waiver but nothing specific to the facility. Facilities must develop and implement policies and procedures that describe its role in providing care and collaborating with local emergency officials at alternate care sites during emergencies. In an interview on 11/16/18 at approximately 2:50pm, the Assistant Administrator stated that they will update and revise the policies and procedures.

Plan of Correction: ApprovedDecember 5, 2018

E026 - 1135 WAIVER
I. Immediate Corrective Action
1. The administrator has reviewed with Žthe emergency management team to update and develop the provisions for an 1135 waiver section of the Comprehensive Emergency Preparedness Plan.
2. The Administrator will develop a Comprehensive Emergency Preparedness Plan, which utilizes and all hazards approach. The plan will include policy and procedures for the provision of care under an 1135 waiver at alternate care sites.

II. Identification of Other Residents
1.The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
III.Systemic Changes
1. The Administrator, in conjunction with the Director of Maintenance, Director of Nursing and Medical Director, reviewed and revised the facility emergency policies and procedures and incorporated the provision of care at an alternate care site during an emergency into the Comprehensive Emergency Preparedness Plan.
2. The Director of Inservice Education will inservice all facility staff on the facility Emergency Preparedness Plan, including the facility procedure for the provision of care at alternate care sites during an emergency.
3. Attendance Records will be maintained for reference and validation.

4. IV. QA Monitoring
1. The Administrator, in conjunction with the Director of Maintenance and Inservice coordinator, will conduct Emergency Preparedness Drills and/or Tabletop exercises with facility staff for the next 3 months, then bi-annually thereafter. Documentation of drill and critiques of staff performance will be maintained in logbook for reference and validation.
2. The Director of Maintenance will review the staff response to Emergency Preparedness Drills and Tabletop exercises, including the tracking if staff component of plan, and present findings to the QA Committee on a monthly basis, for evaluation by the QA Committee.
3. Drill response that reveals negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.
V. All corrective actions will be completed by the Administrator by 1/20/2019

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.2 High-rise buildings shall comply with 19.4.2. 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1). 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13 8.6 Standard Pendent and Upright Spray Sprinklers. 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. 8.6.1 General. All requirements of Section 8.5 shall apply to standard pendent and upright spray sprinklers except as modified in Section 8.6. 8.6.3.3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. 8.3.3.1* Sprinklers in light hazard occupancies shall be one of the following: (1) Quick-response type as defined in 3.6.4.7 (2) Residential sprinklers in accordance with the requirements of 8.4.5 (3) Standard-response sprinklers used for modifications or additions to existing light hazard systems equipped with standard-response sprinklers (4) Standard-response sprinklers used where individual standard-response sprinklers are replaced in existing light hazard systems 8.3.3.2 Where quick-response sprinklers are installed, all sprinklers within a compartment shall be quick-response unless otherwise permitted in 8.3.3.3. The requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that the automatic sprinkler system was installed throughout the building in accordance with the requirements of NFPA 13. This occurred on three out of nine floors of the building. The findings include: 1)During the life safety portion of the recertification survey on 11/14/2018 between 9:30 am and 3:00 pm, pendent type sprinkler heads were noted installed less than four inches from the wall in locations including but not limited to: a)The wall adjacent to the rest room in the first-floor administrator's office. b)The first-floor visitors women's room off the main lobby. c)The vestibule of the eighth-floor medication room near the nurses' station. 2)During the life safety portion of the recertification survey on 11/15/2018 at approximately 11:45 am, it was noted that the main kitchen storage room in the basement kitchen was supplied with one quick response sprinkler head, while the other sprinkler heads in the room were standard response. During interviews concurrent with these findings, the Maintenance Director stated that any sprinkler heads located less than 4 inches from a wall would be moved or replaced with sidewall sprinklers, and the quick response sprinkler head in the kitchen storage would be replaced with a standard response head. 2012 NFPA 101 2010 NFPA 13 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedDecember 5, 2018

K351 - SPRINKLER INSTALLATION
I. Immediate Corrective Action
No individual residents were found to be affected by the deficient practice.
1. The Director of Environmental Services contacted the facility?s sprinkler maintenance company and scheduled the installation of same type and relocation of the identified sprinkler heads.
2. The pendent type sprinkler heads noted installed less than four inches from the wall in locations:
a) The wall adjacent to the rest room in the first-floor administrator's office.
b) The first-floor visitors women's room off the main lobby.
c) The vestibule of the eighth-floor medication room near the nurses' station.
d) The main kitchen storage room in the basement kitchen which was supplied with one quick response sprinkler head had the other sprinkler heads in the room were replaced with quick response.
3. The facility engineer with a licensed sprinkler installer and professional engineer has reviewed all other areas for proper sprinkler coverage and found no other required sprinklers missing
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
1. The Director of Environmental Services inspected all other sprinkler heads and found them to be in reliable operating condition.
2. No additional quality issues were identified.
III. Systematic Changes
1. The sprinkler maintenance company will add inspection of the sprinkler heads to their preventive maintenance inspection/ testing. Any sprinkler heads identified will be immediately replaced. Quarterly inspections of the system and facility shall be conducted by certified company and records maintained accordingly.
2. The Director of Maintenance has developed an audit tool to use for monthly inspection of the sprinkler heads in the affected areas.
3. Maintenance staff will be in serviced by the Director of Maintenance on monthly inspection of the system.
4. A copy of attendance records will be kept on file for reference and validation.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

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 minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 19.3.5 Extinguishment Requirements. 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.2 High-rise buildings shall comply with 19.4.2. 19.3.5.3 Where required by 19.1.6, buildings containing hospitals or limited care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 19.3.5.4* The sprinkler system required by 19.3.5.1 or 19.3.5.3 shall be installed in accordance with 9.7.1.1(1). 9.7.1 Automatic Sprinklers. 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2010 NFPA 13 26.1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested , and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 2011 NFPA 25 13.2.5* Main Drain Test. A main drain test shall be conducted annually at each water-based fire protection system riser to determine whether there has been a change in the condition of the water supply piping and control valves. (See also 13.3.3.4.) 13.2.5.1 In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis. 13.3.3.5* Supervisory Switches. 13.3.3.5.1 Valve supervisory switches shall be tested semiannually. 13.4.2 Check Valves. 13.4.2.1 Inspection. Valves shall be inspected internally every 5 years to verify that all components operate correctly, move freely, and are in good condition. 14.2 Internal Inspection of Piping. 14.2.1 Except as discussed in 14.2.1.1 and 14.2.1.4 an inspection of piping and branch line conditions shall be conducted every 5 years by opening a flushing connection at the end of one main and by removing a sprinkler toward the end of one branch line for the purpose of inspecting for the presence of foreign organic and inorganic material. 14.2.1.1 Alternative nondestructive examination methods shall be permitted. 14.2.1.2 Tubercules or slime, if found, shall be tested for indications of microbiologically influenced corrosion (MIC). 14.2.1.3* If the presence of sufficient foreign organic or inorganic material is found to obstruct pipe or sprinklers, an obstruction investigation shall be conducted as described in Section 14.3. 14.3 Obstruction Investigation and Prevention. 14.3.1* An obstruction investigation shall be conducted for system or yard main piping wherever any of the following conditions exist: (1) Defective intake for fire pumps taking suction from open bodies of water (2) The discharge of obstructive material during routine water tests (3) Foreign materials in fire pumps, in dry pipe valves, or in check valves (4)*Foreign material in water during drain tests or plugging of inspector's test connection(s) (5) Plugged sprinklers (6) Plugged piping in sprinkler systems dismantled during building alterations (7) Failure to flush yard piping or surrounding public mains following new installations or repairs (8) A record of broken public mains in the vicinity (9) Abnormally frequent false tripping of a dry pipe valve(s) (10) A system that is returned to service after an extended shutdown (greater than 1 year) (11) There is reason to believe that the sprinkler system contains sodium [MEDICATION NAME] or highly corrosive fluxes in [MEDICATION NAME] systems (12) A system has been supplied with raw water via the fire department connection (13) Pinhole leaks (14) A 50 percent increase in the time it takes water to travel to the inspector's test connection from the time the valve trips during a full flow trip test of a dry pipe sprinkler system when compared to the original system acceptance test. The requirement is not met as evidenced by: Based on document review and staff interview during the recertification survey, the facility did not ensure that the automatic sprinkler system was tested and maintained in accordance with the requirements of NFPA 25. The findings include: A review of the facility's sprinkler testing and maintenance documents during the recertification survey on 11/15/2018 between 1:00pm and 3:00pm, it was noted that the following required tests had not been done on the automatic sprinkler system: 1)Five -year check valve inspection. 2)Five- year internal inspection for organic and inorganic matter. 3)Five- year obstruction test. 4)Quarterly main drain test. 5)Annual back flow preventer test. 6)Semi-annual testing of tamper switches and electrical devices. 7)The dry type sprinkler heads in the walk in- refrigerators and freezers in the main kitchen were not tested or replaced ten years after their installation date. The facility was unable to provide documentation showing that any inspections were done on the system subsequent to April, (YEAR). Upon interview at the exit conference of 11/16/2018 at approximately 2:30 pm, the Maintenance Director stated that the facility would contract with a sprinkler company to perform the necessary testing. 2012 NFPA 101 2010 NFPA 13 2011 NFPA 25 10 NYCRR 711.2(a)

Plan of Correction: ApprovedDecember 5, 2018


K 353 - SPRINKLER TESTING
I. Immediate Corrective Action
No individual residents were found to be affected by the deficient practice.
1. The Director of Maintenance contacted the facility?s sprinkler maintenance company and scheduled the following required tests on the automatic sprinkler system:
a) Five -year check valve inspection to be accomplished and witnessed by NYFD
b) Five- year internal inspection for organic and inorganic matter.
c)Five- year obstruction test.
d) 13.2.5.1 In systems where the sole water supply is through a backflow preventer and/or pressure reducing valves, the main drain test of at least one system downstream of the device shall be conducted on a quarterly basis.
Quarterly main drain test not required as there is no backflow or reducer installed.
2. The Fire alarm service company provided the required Semi-annual testing of tamper switches and electrical devices.
2. The dry type sprinkler heads in the walk-in refrigerators and freezers in the main kitchen were replaced.
II. Identification of other Residents
The Facility respectfully states that all residents were potentially affected; however, no residents were involved in this deficiency.
No other inspection requirements were missed.
III. Systematic Changes
1. The sprinkler maintenance company will update inspection of the sprinkler system to their preventive maintenance inspection/ testing. Quarterly inspections of the system and facility shall be conducted by the certified company and records maintained accordingly.
2. The Facility will have quarterly inspections completed by a licensed sprinkler company for appropriate NFPA 25 compliance.
3. The Director of Maintenance has developed an audit tool to use for monthly inspection.
4. Maintenance staff will be in serviced by the Director of Maintenance on monthly inspection of the system.
5. A copy of the attendance records will be kept on file for reference and validation.
IV. Q/A Monitoring
1. The Director of Maintenance will conduct monthly audits over the next quarter.
2. Audits of negative findings will have immediate corrective actions implemented.
3. Audit findings will be presented monthly to the Administrator and to the QA Committee quarterly for evaluation and follow up.
V. All corrective actions will be completed by the Director of Maintenance by 1/20/2019

SUBSISTENCE NEEDS FOR STAFF AND PATIENTS

REGULATION: [(b) Policies and procedures. [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 every 2 years (annually for LTC). At a minimum, the policies and procedures must address the following: (1) The provision of subsistence needs for staff and patients whether they evacuate or shelter in place, include, but are not limited to the following: (i) Food, water, medical and pharmaceutical supplies (ii) Alternate sources of energy to maintain the following: (A) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (B) Emergency lighting. (C) Fire detection, extinguishing, and alarm systems. (D) Sewage and waste disposal. *[For Inpatient Hospice at §418.113(b)(6)(iii):] Policies and procedures. (6) The following are additional requirements for hospice-operated inpatient care facilities only. The policies and procedures must address the following: (iii) The provision of subsistence needs for hospice employees and patients, whether they evacuate or shelter in place, include, but are not limited to the following: (A) Food, water, medical, and pharmaceutical supplies. (B) Alternate sources of energy to maintain the following: (1) Temperatures to protect patient health and safety and for the safe and sanitary storage of provisions. (2) Emergency lighting. (3) Fire detection, extinguishing, and alarm systems. (C) Sewage and waste disposal.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: November 20, 2018
Corrected date: January 20, 2019

Citation Details

Based on documentation review and staff interview, the facility's Emergency Preparedness plan did not address policies and procedures regarding the provision of subsistence needs for staff whether they evacuate or shelter in place, regarding food, medical and pharmaceutical supplies. The facility's policy was not specific to providing subsistence needs for water and medications for staff and residents. The findings are: On 11/16/2018 between 12:00pm- 2:15pm during the recertification survey, review of the facility's Emergency Preparedness plan revealed that their policy did not specifically address subsistence needs for staff regarding water, medical and pharmaceutical supplies. There was no policy and procedure in the Emergency Preparedness plan specific to providing supplies needed to shelter-in-place to support necessary staff. The facility must be able to provide for adequate subsistence for all residents and staff for the duration of an emergency or until all its residents have been evacuated and its operations cease. In an interview on 11/16/18 at approximately 2:40 pm, the Assistant Administrator stated that they will update and revise this policy.

Plan of Correction: ApprovedDecember 5, 2018

E015 - SUBSISTENCE NEEDS FOR STAFF AND PATIENTS
I. Immediate Corrective Action
1. The Administrator reviewed with Žthe emergency management team and updated the shelter in place subsistence section of the Comprehensive Emergency Preparedness Plan.
2. The Administrator Has developed a Subsistence Emergency Preparedness Plan, which utilizes and all hazards approach. The plan will include policy and procedures for suppling food, water and any other items required for the safety and health of on-duty staff within or relocated outside facility during emergency.
II Identification of Other Residents
The Facility respectfully states that all residents were involved in this deficiency, however no residents were directly affected.
III Systemic Changes
1. The Administrator, in conjunction with the Director of Maintenance, Director of Nursing and Medical Director, reviewed and revised the facility emergency policies and procedures and incorporated the Subsistence of on-duty staff within or relocated outside facility during emergency into the Comprehensive Emergency Preparedness Plan.
2. The Director of Inservice Education will inservice all facility staff on the facility Emergency Preparedness Plan, including the facility procedure for Subsistence of staff both inside and outside of facility during an emergency.
3. Attendance Records will be maintained for reference and validation.
IV QA Monitoring
4. The Administrator, in conjunction with the Director of Maintenance and Inservice coordinator, will conduct monthly Emergency Preparedness meetings and/or Table Top exercises with facility staff for the next 3 months, then bi-annually thereafter. Documentation of drill and critiques of staff performance will be maintained in logbook for reference and validation.
5. The Director of Maintenance will review the staff response to Emergency Preparedness Drills and Tabletop exercises, including the Subsistence of staff component of plan, and present findings to the QA Committee on a monthly basis, for evaluation by the QA Committee.
6. Drill response that reveals negative or incorrect response will be immediately reported to the Administrator and Director of Nursing for further action.
V. All corrective actions will be completed by the Administrator by 1/20/2019