St Anns Community
February 25, 2019 Certification/complaint Survey

Standard Health Citations

FF11 483.21(a)(1)-(3):BASELINE CARE PLAN

REGULATION: §483.21 Comprehensive Person-Centered Care Planning §483.21(a) Baseline Care Plans §483.21(a)(1) The facility must develop and implement a baseline care plan for each resident that includes the instructions needed to provide effective and person-centered care of the resident that meet professional standards of quality care. The baseline care plan must- (i) Be developed within 48 hours of a resident's admission. (ii) Include the minimum healthcare information necessary to properly care for a resident including, but not limited to- (A) Initial goals based on admission orders. (B) Physician orders. (C) Dietary orders. (D) Therapy services. (E) Social services. (F) PASARR recommendation, if applicable. §483.21(a)(2) The facility may develop a comprehensive care plan in place of the baseline care plan if the comprehensive care plan- (i) Is developed within 48 hours of the resident's admission. (ii) Meets the requirements set forth in paragraph (b) of this section (excepting paragraph (b)(2)(i) of this section). §483.21(a)(3) The facility must provide the resident and their representative with a summary of the baseline care plan that includes but is not limited to: (i) The initial goals of the resident. (ii) A summary of the resident's medications and dietary instructions. (iii) Any services and treatments to be administered by the facility and personnel acting on behalf of the facility. (iv) Any updated information based on the details of the comprehensive care plan, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 25, 2019
Corrected date: April 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for five of eight residents reviewed for Baseline Care Plans, the facility did not provide documented evidence that the resident or representative was provided a written summary of the baseline care plan that included the minimum required healthcare information necessary to properly care for a resident (Residents #32, #64, #69, #46, and #7). This is evidenced by, but not limited to, the following: The facility policy and procedure, Care Planning- Interdisciplinary, last reviewed on 12/30/17, included that a baseline care plan would be initiated and completed within 48 hours of admission and address at the minimum the following: initial goals based on admission orders [REDACTED]. A copy of the baseline care plan, the resident's care card, and a list of the resident's current medication will be provided to the resident or their representative, and a note will be written in the electronic health record to confirm that information was provided. 1. Resident #32 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 12/21/18, revealed the resident had severely impaired cognition. The Baseline Care Plan was developed within 48 hours of admission; however, the Care Plan Meeting Form, dated 5/9/18, revealed the care plan was provided on that date but did not include initial goals for the resident, a list of current medication, or dietary instructions. 2. Resident #64 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/30/19, revealed the resident had severely impaired cognition. Review of the electronic medical record revealed the Baseline Care Plan, effective 1/29/18 to 2/6/18, included initial goals for care but did not include a list of current medications. The Care Plan Meeting Form, dated 2/14/18, revealed that a meeting was held on 2/16/18 to include the resident's family member and members of the interdisciplinary team, and a copy of the care plan was provided to resident/patient/family at that time. 3. Resident #69 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/22/19, revealed the resident had moderately impaired cognition. Review of the electronic medical record revealed a Baseline Care Plan, effective 1/15/19 to 1/24/19, included initial goals for care but did not include a list of current medications. A progress note documented by a Social Worker on 1/29/19 at 10:59 a.m. revealed that a copy of the resident's care plan was provided to the Health Care Proxy on that date. When interviewed on 2/21/19 at 10:06 a.m., the Registered Nurse Manager stated that medications were incorporated into the Comprehensive Care Plan (CCP) and a copy of the CCP was provided to the resident and/or family. When interviewed on 2/22/19 at 11:50 a.m., the Social Worker stated that the baseline care plan is started at the time of admission and rolls into the CCP. She said the CCP is given to the family or resident prior to the CCP meeting. She said that the physician orders [REDACTED]. When interviewed on 2/25/19 at 1:03 p.m., the Director of Quality and Risk Management stated that she was unable to find that physician and therapy orders were included in the baseline care plan. She said that she did not know where information would be documented regarding the contents of the baseline care plan summary that was provided to the resident or representative.

Plan of Correction: ApprovedMarch 20, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 655
Corrective Action:
1. On [DATE] comprehensive care plan to include initial goals, medication list and diet orders/instructions were provided to the HCP for resident #32 in addition to the [DATE] care plan delivered which included initial goals and diet orders.
2. On [DATE] a medication list was provided to the HCP for resident #64
3. Resident #69 is deceased
Responsible Party:
Nurse Manager
Director of Nursing
Identification of other residents affected:
On [DATE] an e-mail was sent to all resident contacts to offer a care card and medication list.
Completed by [DATE]
Responsible Party:
Nurse Manager
Director of Nursing
Social Worker
Systemic Changes:
Policy TX-61 has been reviewed by the interdisciplinary team and will be updated to highlight the required deliverables of a medication list, care plan and care card will be offered to the resident and/or resident representative. Education will be provided to all members of the interdisciplinary team on the care plan policy.
Completed by:
[DATE]
Responsible Party:
Director of Quality
Director of Staff Development
Quality Assurance:
An audit of all new admissions will be conducted every month for 3 months for delivery of the Baseline/Comprehensive care plan, medication list and care card prior to the care plan meeting.
Results will be reported at the QAA Monthly Meeting.
First Audit will be complete by [DATE]
Responsible Party:
Director of Nursing
Director of Quality

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 25, 2019
Corrected date: April 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #40) of three residents reviewed for splints, the facility did not implement interventions in accordance with the resident's plan of care. Specifically, the resident was not consistently wearing his splint as care planned. This is evidenced by the following: Resident #40 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/9/19, revealed the resident's cognitive skills for daily decision making were severely impaired, the resident had upper and lower extremity impairment on both sides, and required the extensive assistance of staff for dressing, eating, and personal hygiene. The Occupational Therapy Evaluation, dated 3/26/16, revealed that the resident was to wear a left elbow Dynapro splint to help with tone management and to prevent further contractures. The (MONTH) 2019 physician treatment orders included that the resident was to have a Dynapro flex elbow splint in place always and to remove the splint for hygiene. The current Resident Care Summary (directs cares) revealed that the resident always wore a Dynapro left elbow splint and directed to remove the splint for hygiene and skin checks. During an observation on 2/19/19 at 9:37 a.m., the resident was without a splint on the left elbow. On 2/22/19 at 8:55 a.m., the resident was sleeping in bed with no splint on the left elbow. Interviews conducted on 2/22/19 included the following: a. At 8:55 a.m., the Certified Nursing Assistant (CNA) stated she was in such a hurry that she forgot to apply the resident's splint. b. At 10:06 a.m., the Registered Nurse Manager stated that the CNA was responsible for putting on the splints. She said that she expects staff to follow the care plan. When interviewed on 2/25/19 at 11:55 a.m., the Occupational Therapist said the resident wore the elbow splint for tone reduction management and to prevent further contractures. (10 NYCRR 415.11(2)(ii))

Plan of Correction: ApprovedMarch 20, 2019

F 656
Corrective Action:
1. On 2/25/2019 OT evaluated resident #40 for upper extremity range of motion and effectiveness of splint.
Responsible Party:
Occupational Therapist
Identification of other residents affected:
All residents care cards will be reviewed for therapeutic splint order. Residents identified with a splint will have a medical treatment order entered.
Complete date:
3/20/19
Responsible Party:
Nurse Manager
Clinical Coordinator
Systemic Changes:
All Nursing and therapy staff will be reeducated on the development and implementation of the care card to include application and use of splints. Education will also be provided on creating a medical order for therapeutic splints.
Complete date:
4/16/2019
Responsible Party:
Director of Education
Quality Assurance:
An audit of 5 care cards per month for three months will be reviewed to ensure that care card directions have been implemented. Results will be reported at the monthly QAA meeting.
First audit complete by:
4/25/19
Responsible Party:
Director of Nursing
Director of Quality

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 25, 2019
Corrected date: April 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #49) of three residents reviewed for accidents, the facility did not ensure the resident's environment remained free from accident hazards and each resident received adequate supervision to prevent avoidable accidents. Specifically, interventions were not re-evaluated for a resident with multiple skin tears, and there was a lack of an assessment for a decline in transfer status. This is evidenced by the following: Resident #49 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 1/15/19, revealed the resident was cognitively intact, had skin tears, and required extensive assistance of staff for transfers and supervision (oversight and cueing) with locomotion off the unit. The current Resident Care Summary (directs care) included the resident was independent with the power wheelchair, instructions to staff to provide frequent safety reminders while maneuvering the power wheelchair, and to remind the resident to keep the power wheelchair in P1 or P2 (speed) setting. The resident required the extensive assistance of two staff with a Vander lift (a lift using a sling where the resident does not bear weight) for transfer to a shower chair but a two-assist stand pivot transfer in and out of bed and no gait belt. The current Comprehensive Care Plan (CCP) identified the resident had vision and hearing impairments (the resident decided when to wear his glasses and or hearing aids), was at risk for injury related to poor safety awareness related to the use of a motorized wheelchair, was at risk for alterations in skin integrity related to fragile skin, and he refused to wear skin sleeves. Interventions included Physical Therapy (PT)/Occupational Therapy assessment as needed. Review of the most recent PT discharge summary, dated 9/28/18, included that the resident was independent with the power wheelchair at speed setting of P1 or P2, requires one assist for pivot transfers from power wheelchair to bed, and an Apex lift for transfers to the toilet. The resident continues to demonstrate impulsive behavior, and if staff feel he is placing himself or others at risk with his driving, then another wheelchair assessment and cognitive assessment would need to be completed. Review of the Speech Language Pathology evaluation, dated 1/3/19, revealed the resident was referred for an assessment of his speech/language and cognitive/linguistic abilities following reports of reduced safety and judgement with the power chair. Staff reported the main concern was the speed at which the resident maneuvered the chair resulting in an increased number of collisions, skin tears, and risk for striking other residents. The Montreal Cognitive Assessment (a screening instrument for mild cognitive dysfunction) revealed a score of 21 out of 30 (normal is greater than or equal to 26). The language, abstraction, and delayed recall sections were significant for deficits. There were no speech recommendations related to the power wheelchair. Review of Incident/Accident Reports, from 12/22/18 through 2/21/19, revealed 12 incidents where the resident sustained [REDACTED]. Interventions included, but were not limited to, the use of skin cream to the resident's upper and lower extremities, to continue to remind the resident regarding safety hazards, and to go slow while in the power wheelchair. Review of an Incident/Accident Report, dated 1/8/19, revealed the resident was being transferred by an Apex lift and two staff when the resident had to be lowered to the floor due to the resident's inability to stand. There were no care plan changes made. On 1/13/19, the Incident/Accident Report revealed that the resident sustained [REDACTED]. On 1/15/19, the Incident /Accident Report revealed staff were utilizing the Apex lift when the resident became weak and was lowered to the floor. Interventions included to change the resident from one assist with Apex lift to two staff assist with Apex lift and no gait belt. There was no PT referral or Registered Nurse (RN) assessment done related to the resident's transfer needs. Observations included the following: a. On 2/19/19 at 9:03 a.m., the resident was in bed and had a dressing to the left mid-forearm that was bleeding. At that time, the resident stated he had received skin tears from catching his arms on the doors. b. On 2/22/19 at 9:25 a.m., the resident was dressed in a short sleeve shirt and shorts and was operating the power wheelchair in his room. The resident was backing the chair up between the end of the bed and a dresser when the front left wheel of the chair caught on the front left corner of the dresser. The resident proceeded to go forward and back several times, catching the dresser each time and dragging the dresser with the power chair. A Certified Nursing Assistant (CNA) in the room stopped the resident and assisted the resident in backing up the chair, tucking in his left arm. When interviewed at that time, the CNA stated she does not give the resident any safety or speed reminders for the safe operation of the power chair but assists him when observed. Interviews conducted on 2/25/19 included the following: a. At 9:01 a.m., the RN stated she had revised the resident's plan of care on 1/16/19 but had not personally assessed the resident's transfer abilities. She stated she had made the change based on what staff told her the resident needed. The RN stated an assessment of the resident should have been completed before changing his transfer status to ensure the use of appropriate devices. She stated the resident does not want to go slower in the motorized chair, bangs into things, and does what he wants. b. At 11:22 a.m., the Occupational Therapist (OT) stated she had been working with the resident on his overall strength and endurance. She said that an evaluation was done by PT for the safe use of the motorized chair in (MONTH) of (YEAR) and that they would need an order to re-evaluate. The OT said she had observed the resident in the motorized chair, he displayed good safety awareness when he operated the chair in the slowest speed, and she thought the speed on the chair could be reduced. c. At 1:45 p.m., after reviewing the resident's CCP for revisions related to the skin issues, the Director of Nursing stated the resident will not wear skin sleeves but offered no other suggestions. (10 NYCRR 415.12(h)(2))

Plan of Correction: ApprovedMarch 20, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 689
Corrective Action:
On 2/26/2019 resident # 49 was seen by medical. [MEDICATION NAME] was adjusted.
On 3/2/2019 OT evaluated resident for safe use of electric wheelchair. Education provided to resident for general safety awareness to avoid injury to self and others, which included use of skin sleeves.
On 3/2/2019 bed assist rails for mobility were padded.
On 3/2/2019 resident transfer status was changed to a vander lift for all transfers.
On 3/5/2019 wheelchair representative responded to a request to reduce speed on the electric wheelchair.
On 3/14/2019 resident room was reoriented for better maneuvering in the room.
Responsible Party:
Occupational Therapist
Director of Nursing
Nurse Manager
Social Work
Identification of other residents affected:
An audit of residents using power wheelchairs will be completed to ensure the resident has been evaluated for safe use and free of injuries.
Complete date:
3/22/2019
Responsible Party:
Nurse Manger
Occupational Therapist
Systemic Changes:
Education will be provided to all RN's on safety assessment with regard to increasing transfer status with devices.
All staff will be educated on Safe Patient Handling as it relates to skin tears and keeping residents free from injury.
Complete date:
4/16/2019
Responsible Party:
Director of Nursing
Director of Education
Quality Assurance:
An audit of all incident reports related to self inflicted skin tears will be conducted every month for 3 months.
Results will be reported at the QAA monthly meeting.
First Audit will be completed by 4/25/19
Responsible Party:
Director of Nursing
Director of Quality

FF11 483.25(a)(1)(2):TREATMENT/DEVICES TO MAINTAIN HEARING/VISION

REGULATION: §483.25(a) Vision and hearing To ensure that residents receive proper treatment and assistive devices to maintain vision and hearing abilities, the facility must, if necessary, assist the resident- §483.25(a)(1) In making appointments, and §483.25(a)(2) By arranging for transportation to and from the office of a practitioner specializing in the treatment of vision or hearing impairment or the office of a professional specializing in the provision of vision or hearing assistive devices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 25, 2019
Corrected date: April 25, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for two (Residents #49 and #61) of three residents reviewed for vision and hearing, the facility did not ensure that residents received proper treatment and or assistive devices to maintain hearing. Specifically, there was no follow up for missing and or broken hearing aids. This is evidenced by the following: 1. Resident #49 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/15/19, revealed the resident was cognitively intact and utilized a hearing aid or other hearing appliances. A Nursing Admission form, dated 1/31/19, revealed the resident had bilateral hearing aids. The current Resident Care Summary (directs care) revealed the resident wore glasses and to face the resident directly while speaking slowly and clearly. The Comprehensive Care Plan (CCP) revealed the resident had visual and hearing impairments and used bilateral hearing aids. Approaches included to keep adaptive equipment in good repair, check the battery regularly, and keep adaptive devices accessible. The resident was at risk for injury, and interventions included to reinforce the use of glasses and hearing aid. When interviewed on 2/19/19 at 9:13 a.m., the resident stated he had lost a hearing aid and needed to make an appointment. Interviews conducted on 2/22/19 included the following: a. At 9:29 a.m., Certified Nursing Assistant (CNA) #1 stated the resident did not wear hearing aids. She stated it would be on the Resident Care Summary if the resident wore hearing aids. b. At 1:37 p.m., Licensed Practical Nurse (LPN) #1 stated the resident does not wear hearing aids and never has. During an interview on 2/25/19 at 12:32 p.m., the Registered Nurse Manager (RNM) stated the resident's care plan included hearing aids and the care card should include that information. She stated if the resident was missing a hearing aid, it should have been documented. At 1:45 p.m., the RNM stated the resident currently had one hearing aide for the left ear, and the right hearing aid had been missing since before 12/25/18. She said that she would follow up on getting a replacement. 2. Resident #61 was admitted to the facility on [DATE] and had [DIAGNOSES REDACTED]. The MDS Assessment, dated 1/29/19, revealed the resident had moderately impaired cognition, moderate difficulty with hearing (speaker must increase volume and speak distinctly,) and utilized hearing aids. The current Resident Care Summary revealed the resident had right and left hearing aids, and when speaking to the resident ,face her directly while speaking clearly and slowly. During an observation and interview on 2/19/19 at 11:40 a.m., the resident stated her right hearing aid has been missing for over two weeks. She said she had trouble focusing on the TV without it, and staff knew her hearing aid was broken. The resident showed the surveyor her broken hearing aid, which was in a box on her tray table, and then stated she had been wondering when it was going to get fixed. When interviewed on 2/20/19 at 2:31 p.m., CNA #2 stated she called the Unit Secretary several times to schedule an appointment for the resident with the audiologist. The CNA stated the audiologist came in and fixed the resident's broken hearing aid, and the next day the other hearing aid was broken. The CNA stated she thought she had called the Unit Secretary over two weeks ago for an appointment. When interviewed on 2/21/19 at 3:20 p.m. LPN #2 stated she knew about one hearing aid being sent out for repair but was not aware the other hearing aid was broken. The LPN stated she would speak to the resident and document. She said that once she is notified of a broken hearing aid, she contacts the Unit Secretary who is responsible for scheduling appointments. During an interview on 2/22/19 at 10:06 a.m., the RNM stated the CNAs should report a broken hearing aid to the team leader and then to the Manager or the Clinical Coordinator. She said the Social Worker and family would be notified, and the resident and or family contacted to see what they would like done. The RNM said an appointment would be scheduled with the audiologist. (10 NYCRR 415.12(3)(9)(b))

Plan of Correction: ApprovedMarch 20, 2019

685
Corrective Action
1. On 3/13/2019 the Care Card for resident #49 was updated to match and reflect that the resident wears hearing aids as desired.
Confirmed that family is handling replacement of missing hearing aid as resident manages independently.
2. On 2/26/2019 the right hearing aid was picked up for repair.
Identification of other residents affected
An audit of incident reports pertaining to missing or broken items for the last 6 months will be audited for closure.
Completed by:
3/22/19
Responsible Party:
Director of Nursing

Systemic Changes:
Protocol to be created to address missing and broken items. Education on protocol provided to nursing, social work and HIM associate.
Complete Date: 4/16/2019
Responsible Party:
Director of Nursing
Administrator
Director of Education

Quality Assurance:
An audit of new protocol initiative pertaining to all lost or broken assistive devices will be completed for monthly for three months to ensure process is followed.
Results will be reported monthly at the QAA meeting
The first audit will be completed on 4/25/2019
Responsible Party:
Director of Nursing
Director of Quality

Standard Life Safety Code Citations

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 more than minimal harm
Citation date: February 25, 2019
Corrected date: April 16, 2019

Citation Details

Based on an interview and record review conducted during the Life Safety Code Survey, it was determined that for one of one emergency generator, the emergency generator was not properly maintained. Specifically, monthly generator load tests and weekly inspections were not completed. This is evidenced by the following: On 2/19/19 a record review of the Emergency Generator Testing for (YEAR) revealed there was no record of a load test conducted during (MONTH) of (YEAR). Approximately 84 days passed between documented load tests conducted on 3/7/18 and 5/31/18. Further record review revealed there were no documented weekly inspections of the emergency generator for (MONTH) (YEAR). During an interview on 2/21/19 at 2:45 p.m., the Administrator stated the emergency generator was not tested during (MONTH) (YEAR). Per the 2010 edition of NFPA 110-Emergency and Standby Power Systems, Emergency Power Supply Systems including all appurtenant components, shall be inspected weekly and exercised under load at least monthly. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101:19.5.1, 19.5.1.1, 9.1.3, 9.1.3.1; 2010 NFPA 110: 8.3.4, 8.4, 8.4.1)

Plan of Correction: ApprovedMarch 20, 2019

K 918
Immediate Action:
The generator has been inspected as required weekly and a full load test monthly since (MONTH) (YEAR).

Identification of other areas affected:
On 2/13/19 an audit of all PM books was conducted for accuracy

Systemic Changes:
Education on the generator test procedure will be provided to the facilities team on the required maintenance of the generator.
Complete Date: 4/16/2019

Quality Assurance:
An audit of generator maintenance will be conducted each month for three months. Results will be reported at the monthly QAA meeting.
The first audit will be completed by 3/20/2019
Responsible Party:
Facilities Manger