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Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: February 7, 2025
Citation Details 2012 NFPA 101: 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. 2012 NFPA 101: 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). 2012 NFPA 101: 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. 1. 1* The requirements for spacing, location, and position of sprinklers shall be based on the following principles: (1) Sprinklers shall be installed throughout the premises. (2) Sprinklers shall be located so as not to exceed the maximum protection area per sprinkler. (3) Sprinklers shall be positioned and located so as to provide satisfactory performance with respect to activation time and distribution. 8. 5. 5. 3* Obstructions That Prevent Sprinkler Discharge from Reaching the Hazard. Continuous or noncontinuous obstructions that interrupt the water discharge in a horizontal plane more than 18 in. (457 mm) below the sprinkler deflector in a manner to limit the distribution from reaching the protected hazard shall comply with 8. 5. 5. 3. 8. 6. 3. 3 Minimum Distances from Walls. Sprinklers shall be located a minimum of 4 in. (102 mm) from a wall. 8. 15. 3. 2. 1 In noncombustible stair shafts having non-combustible stairs with noncombustible or limited-combustible finishes, sprinklers shall be installed at the top of the shaft and under the first accessible landing above the bottom of the shaft. Based on observations and staff interviews during the recertification survey, the facility did not ensure that a sprinkler head was installed at the bottom landing of every stair and that sprinkler heads were installed as intended. The findings include but are not limited to: On a tour of the SNF building on 12/04/24, at 1:56 PM, it was noted that sprinkler coverage was lacking at the bottom landing of Stairwell D by a discharge door and 2) in the emergency laundry storage room located in the basement. 3) The Soiled Utility Room had a pendent sprinkler installed closer than four inches from the wall. On 12/05/24, at approximately 8 AM, during a tour of the kitchen, it was noted that a sidewall sprinkler was installed on the ceiling of the dessert refrigerator.4) A tour of the 3rd Floor in the Manor building on 12/09/24 revealed a sidewall sprinkler installed on the ceiling of the Staff Restroom and 5) a pendent sprinkler closer than 4 inches from the wall in the resident's Shower Room. At the time of the findings, the Director of Maintenance stated that all issues would be corrected. 2012 NFPA 101 2010 NFPA 13 10NYCRR 711. 2(a) 10 NYCRR 415. 29 | Plan of Correction: ApprovedDecember 19, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 were identified as being affected by the alleged gap in practice. The facility did not ensure that residents MDS were submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #490 and Resident #572 MDS assessments were submitted immediately to Centers for Medicaid and Medicare Services system and accepted. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. The MDS Coordinators reviewed all resident comprehensive, discharge and significant change assessment for the last 3 months for timely completion and submission. All MDS were completed, submitted and accepted. Responsible Party: MDS Coordinators 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? 1. The Policy and Procedure titled MDS 3. 0 Submission was reviewed to assure compliance with F640 by the Administrator in conjunction with the Assistant Director of RA, Chief Information Officer and Director of QA/PI and revised accordingly. The changes in policy include It is the Policy of Kings Harbor Multicare Center to ensure that all MDSs are submitted to CMS via IQIES within 14 days of completion??ÿ and RA Coordinator will ensure receipt of the IQIES validation report from MIS on a daily basis??ÿ. Responsible Party: Administrator, Assistant Director of RA, Chief Information Officer, Director of QA/PI 2. Inservice education will be provided by the Inservice Coordinator/designee to all MDS Coordinators and Information Technology support personnel on the policy titled MDS 3. 0 Submission??ÿ revised 12/ 2024. Responsible Party: Inservice Coordinator/Designee 3. An Audit tool will be created to ensure that all batch MDS assessments are submitted within the 14 day requirement. Responsible Party: Director of QA/PI 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. All MDS batches will be audited to ensure submission within 14 days of completion, weekly x 4 weeks and then bi-weekly x 5 months. Responsible Party: Assistant Director of RA 2. The results of the MDS submission audit will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 3. Results of the MDS submission audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: February 7, 2025
Citation Details Based on Record reviews and interviews during the Recertification survey from 12/02/2024 to 12/09/2024, the facility did not ensure that all completed resident assessments were submitted and transmitted into the Quality Improvement Evaluation Assessment Submission and Processing in a timely manner. Specifically, 9 (Resident #10, Resident #76, Resident #83, Resident #326, Resident #345, Resident #355, Resident #420, Resident #493, and Resident #572) of 9 Minimum Data Set submissions reviewed for Resident Assessments were not submitted to Centers for Medicaid and Medicare Services system within 14 days of completion. The findings are: The facility's policy and procedure titled Minimum Data Set 3. 0 Submission revised 1/2024 documented it is the policy of Kings Harbor Multicare Center to ensure timely submission of all Minimum Data Sets to Centers for Medicare and Medicaid Services via Internet Quality Improvement and Evaluation System. Resident #10's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/23/2024 and completion date of 10/29/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #76's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/24/2024 and completion date of 10/30/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #83's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/23/2024 and completion date of 10/29/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #326's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/24/2024 and completion date of 10/30/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #345's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/18/2024 and completion date of 11/1/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #355's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/19/2024 and completion date of 10/25/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #420's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/12/2024 and completion date of 10/25/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #493's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/11/2024 and completion date of 10/24/ 2024. The assessment was not submitted as of 12/06/ 2024. Resident #572's quarterly Minimum Data Set 3. 0 with assessment reference date of 10/23/24 and completion date of 10/29/ 24. The assessment was not submitted as of 12/06/ 2024. On 12/09/2024 at 12:30 PM, the Assistant Director of Nursing #3 who is also responsible for Resident Assessments was interviewed and stated, the batch that was scheduled for a 11/06/2024 submission was accidentally missed. They were not aware that the assessments were not submitted until it was pointed out by the surveyor. The Assistant Director of Nursing #3 also stated they just checked the validation report which showed the batch was cued on 11/06/2024 and wasn't submitted. The Assistant Director of Nursing #3 stated Information Technology Support submits the batch once it is cued. The Assistant Director of Nursing #3 further stated the assessments were submitted today. On 12/09/24 at 12:44 PM, the Information Technology Support person was interviewed and stated, they had two files to submit and accidentally one single file was submitted twice. They received two reports and one report indicated duplicate submission and they did not spot the error at that time. The Information Technology Support person further stated they didn't realize this until today that the assessments weren't submitted. On 12/09/24 at 1:03 PM, the Administrator was interviewed and stated, this is the first time this has been an issue. The Information Technology Support person sent the same batch twice. The Administrator further stated it was an honest mistake that happened. 10 NYCRR 415. 11 | Plan of Correction: ApprovedDecember 30, 2024 1. What corrective action(s) will be accomplished for those residents found to have been affected by the deficient practice? Resident # 193 and resident #325 were identified as being directly affected by the alleged gap in practice. The facility did not ensure that an alleged violation involving resident-to-resident physical abuse was reported immediately, but no later than 2 hours after allegations were made to the State Survey Agency. - An investigation was conducted and concluded that the altercation was sudden in nature and was not premeditated. - Resident #193 and #325 were separated. Resident #325 was transferred to another unit. - Resident #193 and #325 were assessed and monitored. - Resident #193 and #325 medical provider and family were notified of the incident. - Resident #193 and #325 were seen and evaluated by the psychologist. - Resident #325 was seen and evaluated by the psychiatrist. - Social Services provided emotional support to residents #193 and # 325. - The incident was reported to the NYS-DOH on 7/29/ 24. - RN #4 was re-educated on actual/allege abuse reporting to ensure that the NYS-DOH is notified within 2 hours after the incident/allegation. - CNA #7 was re-educated on abuse prevention and reporting. 2. How will you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? The facility respectfully states that all residents have the potential to be affected by the alleged gap in practice. All incidents and accidents for the preceding 30 days were reviewed by the Assistant Directors of Nursing to ensure that any incidents of alleged or actual abuse or incidents involving serious injury was reported timely to the DON and Administrator, as required, to the state agency and all other required agencies (i.e. law enforcement when applicable). In the event that non-compliance was identified, the incident will be immediately reported to all required entities and staff involved re-inserviced on the required timeframes to report. Responsible Party: Assistant Directors of Nursing 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not occur? 1. The Policy and Procedure for Abuse- Prohibition Protocol, Types of Abuse, Response/Reporting Prevention/Response/Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and revised accordingly. The change in policy include Any alleged violations involving mistreatment, neglect or abuse, including serious injuries of an unknown source must be reported to the Administrator/Designee, or department director immediately. An immediate investigation must be made and the findings of such investigation must be reported to the: - To the NYSDOH via Electronic Incident Reporting form within 2 hours of occurrence/discovery. Responsible Party: Administrator, DON, Medical Director, QA/PI 2. The Policy and Procedure for Abuse Reporting was reviewed to assure compliance with F609 by the Administrator in conjunction with the Director of Nursing, Director of QA/PI and Medical Director and found to be in compliance. Responsible Party: Administrator, DON, Medical Director, Director of QA/PI 3. Inservice education will be provided by the Inservice Coordinator/designee to all staff on abuse, neglect and mistreatment including injuries of unknown origin regarding reporting requirements related to violations involving abuse to the NYSDOH and NYPD, immediately. Education on Abuse Prohibition Protocol will continue to be provided to staff upon hire and annually thereafter. Highlights of the lesson plan include: - The facility staff must immediately report all alleged violations of mistreatment, neglect and abuse, including injuries of unknown origin and misappropriation of resident property to the RNM/RNS/ADON. An investigation is to immediately follow. - The RNM/RNS/ADON will immediately notify the DON who will notify the Administrator. - Upon notification, the Assistant Director of Nursing/Designee must report alleged violations of mistreatment, neglect and abuse, including injuries of unknown origin and misappropriation of resident property immediately to the NYSDOH and as appropriate to other required agencies (i.e., NYPD). Responsible Party: Inservice Coordinator/Designee 4. The Residents Occurrence Log-In form (SAFETY-967) was reviewed and revised to ensure that actual/allegation of abuse is reported to the NY-DOH within 2 hours of the incident/allegation. Revision of form included adding: - Reportable (Y/N) - Date/Time Reported to DOH - Date/Time Reported to Other Agency Responsible Party: QA/PI 4. How the corrective action(s) will be monitored to ensure the deficient practice will not recur? 1. An audit tool will be developed to monitor the facility's compliance with ensuring that all accidents and incidents are investigated, and abuse is reported timely as per NYSDOH and Federal reporting guidelines. Responsible Party: QA/PI 2. All accidents/ incidents and grievances involving alleged abuse or serious injuries will be audited daily by the Assistant Director of Nursing/designee for 30 days and then monthly for 3 months, using the new audit tool to ensure compliance. Any identified issues will be immediately addressed and shared at the Morning Meeting. Responsible Party: Assistant Director of Nursing/Designee 3. The results of the accidents and incidents audits will be analyzed for trends and patterns. Responsible Party: QA/PI Coordinator 4. Results of the accidents and incidents audit will be presented and discussed at the facility quarterly QA/PI meetings. Responsible Party: QA/PI Coordinator 5. Date for correction and the title of the person responsible for correction of deficiency. Deficiency will be corrected by (MONTH) 7, 2025, 60 days from the survey exit date. Person responsible for correction is the Administrator. |
Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: February 5, 2025
Citation Details Based on interviews during the recertification survey conducted 1/11/23-1/20/22, the facility failed to ensure the resident has the right to exercise their rights as a resident of the facility and as a citizen of the United States for all 145 residents of the facility. Specifically, mail from the United States Postal Service (USPS) was not delivered to residents on Saturdays, thereby denying all residents the same rights provided to other citizens of the general community. Findings include: The undated facility Resident Orientation Handbook documented mail was to be distributed daily on each unit. If a resident had an outgoing letter, staff would assist in getting the mail to the Post Office During a resident group interview on 1/11/23 at 2:30 PM, seven anonymous residents in attendance stated personal mail was not delivered to them on Saturdays. Two residents stated the mail was received at the front desk, sent to the business office during the week for sorting during regular business hours, and Saturday's personal mail was not delivered to the residents. The residents stated Saturday mail would not be distributed until Monday or Tuesday. During an interview with the Business Office Manager on 1/17/23 at 9:32 AM, they stated the mail was received in the business office for sorting. Mail that was addressed to the facility would be set aside and residents' personal mail was given to the Activities Department to deliver to the residents. They stated they did not work weekends, but thought mail was delivered to residents because the Activities Department had staff that worked on Saturdays. During an interview on 1/17/23 at 9:45 AM with the Activities Director, they stated they were responsible for overseeing the residents' personal mail, and they and three additional activity staff members delivered personal mail to residents. If residents received personal mail on Saturdays, it was only in the form of packages from box store vendors. All personal mail coming from the USPS was placed in a white bin and tucked away safely until the Business Office Manager retrieved it on Monday morning for sorting and delivery to the residents. During an interview with certified nurse aide (CNA) #18 on 1/18/23 at 9:44 AM, they stated they sometimes worked at the front lobby desk. The mail was brought to the facility by a postal worker. The mail was in a white bin and was sent to the business office for distribution during the week. On Saturdays, the mail sat in a bin and waited until the business office opened on Mondays. Residents did not get personal mail delivered to them on Saturdays. During an interview with the Administrator on 1/18/23 at 2:30 PM, they stated mail came into the facility and was distributed from the front desk to the residents by the business office and activities staff. Residents should receive personal mail on the same days they would at their home. The front desk, business office and activities department were responsible for overseeing mail delivery. They were not aware residents did not receive personal mail on Saturdays. 10NYCRR 415. 3(c)(l)(i) | Plan of Correction: ApprovedDecember 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2012 NFPA 101 and 2011 NFPA 70, the Director of Engineering immediately instructed the Engineering staff to: 1. Mount the unmounted power strip in use in the IT room, Accounting office and other administrative areas. 2. Remove the extension cord in the 2 West Nursing office. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that extension cords in use are appropriate and power strips in use are mounted in accordance with the 2011 National Electric Code. All findings were deemed to be in compliance. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering, Administrator and QA Director created a policy on use of extension cords and power strips. b. All staff will be informed and educated regarding this new policy, use of extension cords and power strips. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering will develop an audit tool to monitor use of extension cords and power strips. b. Audits will be performed monthly by the Engineering staff x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: February 5, 2025
Citation Details 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: 400. 8 Uses Not Permitted. Unless specifically permitted in 400. 7, flexible cords and cables shall not be used for the following: (1) As a substitute for the fixed wiring of a structure (2) Where run through holes in walls, structural ceilings, suspended ceilings, dropped ceilings, or floors (3) Where run through doorways, windows, or similar openings (4) Where attached to building surfaces Exception to (4): Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of 368. 56(B) (5) Where concealed by walls, floors, or ceilings or located above suspended or dropped ceilings (6) Where installed in raceways, except as otherwise permitted in this Code (7) Where subject to physical damage 10. 2. 3. 6 Multiple Outlet Connection. Two or more power receptacles supplied by a flexible cord shall be permitted to be used to supply power to plug-connected components of a movable equipment assembly that is rack-, table-, pedestal-, or cart mounted, provided that all of the following conditions are met: (1) The receptacles are permanently attached to the equipment assembly. (2)*The sum of the ampacity of all appliances connected to the outlets does not exceed 75 percent of the ampacity of the flexible cord supplying the outlets. (3) The ampacity of the flexible cord is in accordance with NFPA 70, National Electrical Code. (4)*The electrical and mechanical integrity of the assembly is regularly verified and documented. (5)*Means are employed to ensure that additional devices or nonmedical equipment cannot be connected to the multiple outlet extension cord after leakage currents have been verified as safe. 10. 2. 4 Adapters and Extension Cords. 10. 2. 4. 1 Three-prong to two-prong adapters shall not be permitted. 10. 2. 4. 2 Adapters and extension cords meeting the requirements of 10. 2. 4. 2. 1 through 10. 2. 4. 2. 3 shall be permitted. 10. 2. 4. 2. 1 All adapters shall be listed for the purpose. 10. 2. 4. 2. 2 Attachment plugs and fittings shall be listed for the purpose. 10. 2. 4. 2. 3 The cabling shall comply with 10. 2. 3. 10. 3 Testing Requirements - Fixed and Portable. 10. 3. 1* Physical Integrity. The physical integrity of the power cord assembly composed of the power cord, attachment plug, and cord-strain relief shall be confirmed by visual inspection. Based on observation and staff interviews, during the Life Safety Recertification survey on (MONTH) 4, 2024, through (MONTH) 10, 2024, the facility did not ensure that extension cords and power strips were used in accordance with NFPA 70. Specifically, power strips and an extension cord were observed in use. The findings include but are not limited to: 1. unmounted power strips, were observed in use in the IT Room, Accounting Office, and other administrative areas. 2. In the Nursing Office in 2West, a green extension cord was placed under the desk powering equipment. At the time of the findings, the Director of Maintenance stated that the extension cord was being used temporarily and that all power strips would be mounted. 2012 NFPA 101: 9. 1. 2 2011 NFPA 70: 400. 8 10 NYCRR 711. 2(a) | Plan of Correction: ApprovedDecember 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2011 NFPA 101 the observed electrical outlets in rooms P346, M409, M401 and other identified resident floors will be converted to approved GFCI outlets by the Engineering Staff. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility respectfully states that all residents have the potential to be affected by deficient practice. b. The Engineering staff performed an inspection throughout the facility to ensure that all electrical outlets are located within 6 feet of any water source. All identified outlets that are not compliant will be converted to approved GFCI outlets. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. The Director of Engineering reviewed and revised the facility policy on Electrical Outlet Testing to include, GFCI to be used within 6 feet of water source??ÿ. b. All Engineering staff will be informed and educated regarding the revised policy on Electrical Outlet Testing. The education will include proper installation, usage and testing of GFCIs. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering will include in the Environment of Care audit tool to inspect and test all GFCI receptacles. b. Audits will be performed monthly by the Engineering staff to ensure compliance. c. Any issues identified by the audit will be corrected immediately by the Engineering Department. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering |
Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: December 9, 2024
Corrected date: February 5, 2025
Citation Details Based on observation and interview, the facility did not ensure that all electrical systems had approved wiring methods with National Electric Code NFPA 70, 2011 edition. Specifically, outlet receptacles not of the ground-fault circuit interrupter (GFCI) type were located within six feet of sinks, potentially creating an electrical hazard. This occurred on five of five resident floors. The findings are: On a tour of the facility conducted on 12/04/24 through 12/10/24, between 9:00 AM - 4:00 PM, resident rooms P436, M409, M401 and throughout resident floors, were noted with outlet receptacles not of the GFCI type located within 6 feet of a hand washing sink and were observed while in the presence of the Director of Maintenance. The Director of Maintenance stated he would audit the facility for any other instances and change the outlets to GFCI or remove the receptacles and install a blank cover plate. 2012 NFPA 101 2011 NFPA 70: 210. 8(B)(5) | Plan of Correction: ApprovedDecember 31, 2024 1. What corrective actions will be accomplished for those residents found to have been affected by the deficient practice? a. No residents were identified as affected by the deficient practice. b. To comply with 2010 NFPA 13, the Director of Engineering contacted the Fire Safety Sprinkler Company to: 1. Install the lacking fire sprinklers at the bottom landing of stairwell D and the emergency laundry storage room. 2. Appropriate sprinkler will be installed in the soiled utility room, 3rd floor Manor building staff restroom and the residents shower room. 3. The facility has signed a contract for installation and work has commenced. 2. How would you identify other residents having the potential to be affected by the same deficient practice and what corrective action will be taken? a. The facility states that all residents have the potential to be affected by deficient practice. b. The contracted company reviewed sprinkler coverage throughout the facility and no additional areas were identified. 3. What measures will be put in place or what systemic changes you will make to ensure that the deficient practice does not recur? a. All Engineering staff will be informed and educated regarding sprinkler heads that were installed and their location, as well as overview of requirements for sprinkler coverage as per K 351. b. The education will concentrate on the requirements to maintain sprinklers in all needed areas as well as ensure sprinkler heads are installed as required. c. A copy of the attendance will be maintained for reference and validation. 4. How the corrective actions will be monitored to ensure the deficient practice will not recur. i.e. what quality assurance program will be put into practice: a. The Director of Engineering has reviewed and revised the Environment Care Audit tool to ensure proper sprinkler coverage. b. Audits will be performed monthly by the Engineering Director/designee x 5 months and then annually thereafter to ensure compliance. c. Any issues identified by the audit will be corrected by the Engineering Department or our contracted sprinkler company as needed. d. Audit findings will be presented to the QA Committee quarterly for evaluation. 5. Completion Date: (MONTH) 7, 2025 Responsible Person: Director of Engineering |