Jeanne Jugan Residence
March 9, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review conducted during a recertification and abbreviated survey, the facility did not ensure that each portion of the MDS assessment accurately reflect the resident's status. Specifically, the most recent MDS did not accurately document that the resident had a fall without injury. This was evident for 1 resident out of 18 sampled residents. (Resident # 15). The finding is: Resident #15 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS) Assessment 3.0 dated 10/24/17 documented severe cognitive impairment, and limited assist of 1 person with walk in room and corridor, and locomotion on the unit. Section J 1800 titled: Any Falls Since Admission/Entry or Reentry or Prior Assessment documented and that the resident had no falls. The Resident Accident/Incident Report dated 9/29/17 documented that resident sustained [REDACTED]. The Comprehensive Care Plan (CCP) At Risk for Falls/Injury related to impaired balance as evidenced by use of rollator when ambulating created 12/2/16 documented the following: assess judgement/mental status and provide supervision in accordance with needs, encourage use of hearing aid/glasses, encourage use of proper footwear, ensure environment is clutter-free. On 9/29/17 the following interventions were added to the care-plan: ensure both brakes of wheelchair are locked when resident is seated in wheelchair with walker in front of her for safety reasons, PT eval. The MDS did not accurately document the resident's fall during the review period. On 03/09/18 at 02:56 PM, an interview was conducted with the Registered Nurse (RN) #1 responsible for all MDS assessment at the facility who stated that in completing the MDS the residents are interviewed, orders and progress notes are reviewed along with the resident's medical diagnosis. The RN also stated that incident reports are not reviewed when completing the MDS and since the resident's fall had not been documented in the progress notes in the medical record, she was unaware that the resident had sustained a fall. On 03/09/18 at 03:36 PM, an interview was conducted with the Director of Nursing (DNS) who stated that any incidents regarding residents are not documented in the medical record as the expectation is that the incident will be well-documented in the Resident Accident/Incident Report. In addition, the care plan would be updated and the information would be available in the care plan so the RN/MDS (assessor) should have checked the care plan as the information would be there. The DNS also stated that the MDS is not routinely checked to ensure that it is accurate, only Section G- Functional Status is reviewed at the CCP meeting. 415.11 (b)

Plan of Correction: ApprovedMay 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 641
I. Immediate Corrective Action:
Resident # 15
1) On 4/10/18 a submission was made for correction to section J1800 for the MDS dated [DATE] to indicate that the resident did sustain a fall since the last prior assessment.
2) A late entry was made in the medical record to indicate that the resident sustained [REDACTED].
3) The RN responsible for completing the MDS received education and counseling for failure to carefully review the Comprehensive care plans during the MDS assessment.
II. Identification of Others:
1) The facility respectfully states that all residents could potentially be affected by inaccurate coding on the MDS.
2) The MDS coordinator developed a MDS coding tracker tool to validate the accuracy of assessments. She will use it to verify those which have been completed over the past 30 days.
III. Systemic Changes:
1) The DNS created a Policy and Procedure for MDS coding and accuracy. The Policy will require the MSD nurse to use the MDS coding tracker tool on all MDS assessments
2) The MDS RN is responsible to review the Medical Record when completing MDS Assessments to ensure accuracy.
3). The MDS nurse will review the MDS coding tracker tool with the IDT during Care conference to ensure accuracy. Any discrepancies will be addressed.
IV Quality Assurance:
1) DNS/designee will create an audit tool to monitor accuracy of MDS Assessments.
Audits will be done on randomly selected MDSs, 2 per month for 1 year.
V. Persons responsible for this F tag:
MDS Nurse

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: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review conducted during a recertification and abbreviated survey, the facility did not ensure that person-centered care plans with measurable goals, time frames and interventions were developed to address a resident's concerns. Specifically, a care plan was not developed to address the use of an anticoagulant. This was evident for 1 of 5 residents reviewed for Unnecessary Medications out of a Sample of 18 residents. (Resident #16). The facility policy and procedure titled Care Plan dated 9/2017 documented the comprehensive care plan includes measurable objectives and timetables to meet the resident's medical, nursing, mental and psychosocial needs as identified in the comprehensive assessment. The findings are: Resident #16 is an [AGE] year-old admitted to the facility 1/17/17 with [DIAGNOSES REDACTED]. The Admission Minimum (MDS) data set [DATE] documented intact cognition, and that resident received an anti-coagulant on 7 of 7 days during the review period. Review of the Order Summary Report documented the following medication was ordered on [DATE]: -Eliquis Tablet 2.5mg-give 1 tablet by mouth two times a day related to Unspecified [MEDICAL CONDITION] Fibrillation. Review of the Medication Administration Record [REDACTED]. The Comprehensive Care Plan was reviewed to ensure all care plans were included to address care issues related to the resident's [DIAGNOSES REDACTED]. There was no documented evidence that care plans with measurable objectives, time frames and appropriate interventions were developed to address the care of the resident with the use of an anticoagulant. On 03/08/18 at 11:34 AM, an interview was conducted with the Registered Nurse (RN) #1 who stated that on admission I would initiate the MDS schedule and initiate the care plans. Within 24 hours I complete the initial care plans. The RN also stated that when doing a care plan the physician's orders [REDACTED]. In addition, the RN stated that there are potential side effects involved with the use of an anticoagulant and a care plan should have been created. The RN stated that all care plans are currently being reviewed as the RN had been hired on a permanent basis. On 03/08/18 at 03:13 PM, an interview was conducted with the Director of Nursing who stated that care plans are created on admission and cover all areas of the resident's care. The DNS also stated that she usually reviews the care plans to make sure all areas are covered and that care plans are reviewed by the team during care conference and at that time concerns are entered the on the care plan. The DNS further stated that care plans used to be done by a nurse who is no longer employed at the facility and is not sure why a care plan had not been created to address anticoagulant use by the resident. 415.11(c)(1)

Plan of Correction: ApprovedMay 8, 2018

F 656
I. Immediate Corrective Action:
Resident # 15
1) On 3/10/18 a care plan was initiated specific to the use of anticoagulation for resident #16
2) The LPN who historically contributed to care plans is no longer involved with Care Plans.
II. Identification of Others:
1) The DNS obtained a listing of all the residents currently receiving anticoagulation therapy. On 4/13/18, the MDS nurse reviewed all charts to ensure that there was a care plan developed for the use of anticoagulation therapy. Any needed updates were made.
III. Systemic Changes:
1) The DNS will review the Policy and Procedure for Care Plans. The Policy will include that the person-centered care plan with measurable goals, time frames and interventions would be developed for residents receiving anticoagulant therapy. An in-service for all RN staff will be held to review the revised Policy. The lesson plan will focus on:
? The need for the comprehensive care plan to address medical, nursing, mental and psychosocial needs.
? The need for care plan to specify medications being used to treat medical and mental needs.
? The responsibility of the RN to ensure that residents receiving anticoagulation therapy have a care plan in place specific to the use of anticoagulation therapy.
? The responsibility of the RN to initiated a care plan specific to anticoagulation therapy when a resident is newly started on same.
IV Quality Assurance:
1) An audit tool will be developed to monitor compliance with the Care Plan Policy with respect to each resident?s medication regime specific to anticoagulation usage.
2) Audits will be done on all Admission, Quarterly and Annual Care Plans Monthly x12 months.
3) Findings of the audits that need immediate correction will be brought to the DNS. Data analysis from the audits will be reviewed by the QA Committee on a quarterly basis for one year.
V. Persons responsible for this F tag:
DNS, and RN MDS Nurse

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: Actual harm has occurred
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a re-certification and abbreviated survey the facility failed to ensure that residents received adequate supervision and proper use of assistive devices prevent accidents. Specifically; 1) Facility Nursing Staff did not adequately provide training and supervision of a Certified Nurses Assistant (CNA#1) to ensure the implementation of a (CCP) designed to prevent Resident #21 from having an accident with injury while receiving care. Resident #21 required 2 persons assist when applying a sling for stand up lift while sitting in bed, and floor mats were to be at bedside to prevent injury from falls. CNA #1 attempted to perform this task without assistance from another staff member. There was no evidence that floor mats were in place. As a result the resident fell from the bed and sustained a [MEDICAL CONDITION] left clavicle. This was evident for two out of three residents reviewed for Accidents out of a total sample of 18 residents. The findings is: 1) Complaint #NY 642 Resident #21 is a [AGE] year old who was initially admitted to the facility on [DATE]. Admitting Diagnoses: [REDACTED]. The Minimum Data Set (MDS) an assessment instrument dated 02/17/17 documented that the resident was assessed with [REDACTED]. The resident was also assessed with [REDACTED]. The Comprehensive Care Plan (CCP) dated 3/7/17 included interventions required for this resident during transfer, mobility and toileting with two plus person physically assisting the resident with activities of daily living. The CCP instructed CNA to apply sling for stand up lift while resident is in bed. The CCP further instructs to avoid applying sling to resident independently if he is seated at side of the bed. Transfers are to be done by asking for assistance. Keep safety mats on the floor and alarm to be use when resident is in bed always. Facility Incident/Investigation Report dated 03/07/17 and completed on 03/07/17 revealed CNA #1 admitted to washing the resident body. CNA#1 was interviewed by the Director of Nursing (DON) who conducted the investigation. According to the report CNA#1 stated that she dressed the resident half way and wanted to put the sling on him while he was sitting upright in bed, holding on to one of the side rails. CNA #1 reportedly stated that she was in front of the resident and turned her eyes away for a moment when the resident fell off the bed and onto the floor. She reportedly also stated that the resident hit his right shoulder when he fell . The report documented that CNA #1 was asked by the DON how did the resident hurt his left side if he fell on his right side. According to the report CNA #1 stated that he might have hit his left side. On 3/07/17 the resident was sent to the hospital and an X-rays were taken. The X-rays revealed that the resident sustained [REDACTED]. CNA #1 was counseled and suspended. She later returned and resigned from her position. CNA #1 prepared a written statement. In that statement she stated that she was dressing the resident and was about to put the sling on the resident while he was sitting upright in bed, holding onto one of the side rails. She wrote that she was in front of the resident when she noticed his body pushed against her thigh and he fell from the bed. The Resident's CNA Documentation Record (CDR) guides the CNAs on tasks performed and is used to record the care provided to residents. Record review for (MONTH) (YEAR) revealed CNA#1, documented by signing her initials on the CDR, that she transferred the resident. Does not indicate if she transferred the resident by herself or with another staff member. The CNA was not able to be interviewed during the survey. Two attempts were made via telephone to contact CNA #1. There was no answer. On 03/09/18 at 03:12 PM LPN#1 who worked the night of the incident was interviewed. LPN #1 stated that on the morning of the incident CNA#1 called him on the telephone reported that the resident was on the floor. LPN #2 stated when he got to the resident's room he noticed that the resident was lying flat on his back with his head towards the door, partly dressed. He stated that he asked CNA#1 what happened. CNA #1 told him that the resident fell . He stated that the resident was complaining of pain of his left shoulder and arm. He stated that he called the DON and she came immediately to assess the resident. Vital signs were taken and the doctor was called by the DON and the resident was transfered out to the hospital. On 03/09/18 at 04:11 PM a brief interview was conducted with the DON. She stated that the incident was investigated immediately when LPN #1 called to report that the resident was on the floor. She stated that it was about 6:15 AM. She stated that she went to the resident's room and the resident was lying flat on his back on the floor. She stated that she did a head to toe assessment and the resident was complaining of pain in his left shoulder. The doctor was called and made aware of the incident and orders was given to send the resident to the hospital. She asked CNA#1 what happened and her story did not make sense. The DON stated that CNA #1 told her that she was standing right in front of the resident and the resident fell and hit his right shoulder. The DON stated that she questioned CNA#1 again and her story changed. The DON stated that she reviewed footage from the hallway camera. It revealed CNA#1 coming out of the resident room more than once, then she came out of the room to get the nurse. She stated that she was going to terminate CNA #1, but she came in and left a note with human resources to say that she resigned. Staff were in-serviced on accidents, falls, abuse, neglect, and mistreatment of [REDACTED]. The DON was asked to provide the footage from the camera. She stated that they do not have it. She stated CNA#1 was in-serviced prior to the accident/incident on resident right and abuse preventions. A review of the Employee File/Records for CNA#1 revealed individual education and attendance sheets were identified for the following date:03/28/2016 on topics: Resident Rights and Abuse Prevention, Employee Responsibilities; Needs of the Elderly; Quality Assurance/Improvement; HIPPA; Fire safety; Infection Control/Prevention; Handwashing. There was no documented evidence that CNA #1 was inserviced on prevention of accidents, or abuse after 3/28/2016.There was no documented evidence that CNA #1 was trained or demonstrated competence on the application and use of the sling on a resident while in bed. The facility did not provide evidence either through documentation or interviews that CNA#1 was adequately trained or supervised to ensure that the resident's CCP instructing 2 person assist and proper use of assistive devices to prevent an accident during care was implemented. The resident's CCP instructed the use of floor mats as an intervention to prevent injury from potential falls. The facility investigative report does not indicate that mats were observed on the floor. The interviews of the DON and LPN #1 did not reveal that the use of this intervention was being monitiored. 415.12(h)(2)

Plan of Correction: ApprovedMay 8, 2018

Directed P(NAME) F 689
I. Immediate Corrective Action:
Resident # 21
1) The resident was reassessed by IDT team to ensure Fall Prevention plan of care was reviewed and revised. The Resident CCP and CNA Kardex was reviewed and updated to reflect current status.
2) The CNA assigned to Resident # 21 at the time of occurrence no longer works at the facility.
3) On 4/6/18 the facility contracted the services of GNYHCFA to develop and implement the directed plan of correction and directed inservice.
4) On 4/10/18 the GNYHCFA consultants convened the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.
II. Identification of Others:
1) The facility respectfully states that all residents were potentially affected.
2) All CNAs have successfully completed a documented return demonstration of both a full body mechanical lift and sit to stand lift. In addition, all CNAs complete a mechanical lift competency upon orientation and annually.
3) On 4/10/18 the facility reviewed and updated the list of all residents using mechanical lifts.
4) The DNS in conjunction with the Inservice Coordinator reviewed the employee training records for all CNAs to ensure all CNAs have completed a mechanical lift competency.
III. Systemic Changes:
1) The DNS in conjunction with the GNYHCFA Consultants reviewed and revised the facility P/P for:
A) Fall Prevention This P/P will be
Inserviced to all nursing staff by GNYHCFA Consultants. The lesson plan will focus on:
? All residents will have a Fall Risk assessment completed by RN on Admission/Readmission, upon significant change and quarterly.
? RN will initiate and implement Fall Prevention care plan for all residents at risk for falls.
? RN will document all interventions and assistive devices for fall prevention on CNA Kardex including hourly monitoring as needed.
? The CNA will sign for resident interventions including transfers. CNA will report to Charge Nurse any instance where individual plan of care cannot be completed.
? The Charge nurse on each unit will conduct unit report for all CNAs at the beginning of each shift discussing all residents on 24-hour report including new admissions, residents with falls and significant changes in condition.
? The Unit Charge Nurse will conduct Unit Safety Rounds each shift to ensure compliance with residents? plan of care specific to prevention of accidents including the use of mechanical lifts.
?IDT Team members will Review and update Fall Prevention Care plan after each fall, quarterly and as needed.
B) The DNS, Administrator and Inservice Coordinator in conjunction with GNYHCFA Consultants reviewed the facility CNA Inservice program to ensure upon orientation, annually and as needed CNAs receive education on Fall Prevention including mechanical lift return demonstration competency and Abuse Prevention ensuring following residents plan of care. This P/P will be inserviced by the GNYHCFA Consultants to all nursing staff. The lesson plan will focus on:
? All CNA staff will complete competency-based training in the use of mechanical lifts upon orientation, annually and as needed.
? The Inservice Coordinator will conduct and document tracking to ensure all CNAs receive required Inservice training including competency-based return demonstration on the use of mechanical lifts upon orientation and annually.
All lesson plans and sign in sheets will be kept on file for validation.
IV Quality Assurance:
1) The GNYHCFA Consultants developed an audit tool to monitor the facility?s compliance with ensuring each resident receives adequate supervision, monitoring and interventions to prevent accidents and incidents including validating that Unit Safety Rounds are conducted each shift. This Audit will be completed by DNS/ In-service Coordinator. Weekly x 3 months followed by monthly x 12 months. All findings will be discussed at monthly QA and quarterly Safety Committee meetings.
2) The GNY Consultants developed an audit tool to monitor the facility?s compliance with ensuring all CNAs participate in Fall Prevention education and complete a mechanical lift competency upon orientation, annually and as needed. This audit will be completed by the Inservice Coordinator for 4 randomly selected staff members weekly x 4 weeks followed by 4 staff members monthly thereafter

All findings will be discussed at monthly QA Committee and Safety Committee meetings for input and follow up as indicated.

V. Persons responsible for this Ftag: Administrator, DNS, Inservice Coordinator.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: §483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards; §483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

Based on observation, and staff interview, the facility failed to maintain and develop an infection control the facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not develop a plan to identify where Legionella and other opportunistic waterborne pathogen could grow and spread within the facility water system. Review of the facility water management plan revealed that it did not include any testing to reduce the risk of growth and spread of Legionella and other opportunistic pathogens. The finding is: Review of the facility Water Management Program dated 10/2/17 did not document that testing of potable water was performed to identify potential sources of Legionella. An interview was conducted with the Director of Nursing (DON) on 03/09/18 at 03:36 PM. The DON who stated that testing was not done as we did not think we had to do it unless they suspected that they had a problem. The DNS also stated that the facility had contracted with a company to have it done in the future. 415.19 (a) (1-3)

Plan of Correction: ApprovedMay 8, 2018

Jeanne Jugan Residence
Directed P(NAME) F880
I. Immediate Corrective Action:
1) On (MONTH) 6, (YEAR) during the recertification the facility retained the services of New York Environmental to complete water testing for legionella and other water borne pathogens.
2) Water samples were sent on (MONTH) 12, (YEAR).
3) Results came back on (MONTH) 28, (YEAR) indicated no legionella or other waterborne pathogen detected.
4) On 4/6/18 the facility contracted the services of GNYHCFA to develop and implement the directed plan of correction and directed inservice.
5) On 4/10/18 the GNYHCFA consultants will convene the facility QA Committee to assess the causative factors that may have contributed to the deficiencies cited, to identify and correct causative factors, identify routine triggers to alert facility of any evolving issues and develop audit tools to monitor facility compliance with the plan of correction.

II. Identification of others:
1) The facility respectfully states that all residents were potentially affected by the lack of water testing.

III. Systemic Changes:
1)The facility in conjunction with GNYHCFA Consultants reviewed and revised the facility?s Water Management P/P. This P/P will be inserviced to the Administrator and Maintenance Director by GNYHCFA. The lesson plan will focus on:
?The facility will conduct routine Legionella culture sampling and analysis at intervals not to exceed 90 days in the first year and annually thereafter.
?The facility will use an NYS approved lab for testing
?The facility will keep all assessments and testing records for a minimum of 3 years.
?The facility will report any positive legionella testing results to the NYSDOH
?In the event of a positive culture the, Administrator, Director of Maintainence and the Infection Control Nurse will be notified.
?Decontamination of the affected system will be implemented, under direction an authorized agency.
? Administrative Team actions will include evaluation of further restrictions on the use of potable water for high risk residents.
Lesson plans and sign in sheets will be kept on file as validation.
IV. Quality Assurance:
1)GNYHCFA Consultants developed an audit tool to monitor the facility?s compliance with ensuring testing of potable water sources to identify and prevent the transmission of Legionella. This audit tool will be completed by the facility?s Director of Maintenance monthly x 3 months followed by quarterly thereafter. Any issues will be reported to QA Committee for follow up as indicated.
V. Person(s) Responsible for this FTag:
Director of Maintenance.

FF11 483.45(g)(h)(1)(2):LABEL/STORE DRUGS AND BIOLOGICALS

REGULATION: §483.45(g) Labeling of Drugs and Biologicals Drugs and biologicals used in the facility must be labeled in accordance with currently accepted professional principles, and include the appropriate accessory and cautionary instructions, and the expiration date when applicable. §483.45(h) Storage of Drugs and Biologicals §483.45(h)(1) In accordance with State and Federal laws, the facility must store all drugs and biologicals in locked compartments under proper temperature controls, and permit only authorized personnel to have access to the keys. §483.45(h)(2) The facility must provide separately locked, permanently affixed compartments for storage of controlled drugs listed in Schedule II of the Comprehensive Drug Abuse Prevention and Control Act of 1976 and other drugs subject to abuse, except when the facility uses single unit package drug distribution systems in which the quantity stored is minimal and a missing dose can be readily detected.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and staff interviews conducted during a recertification survey, the facility did not ensure that all medications and biologicals were stored and labeled properly. Specifically, one opened and undated vial of insulin was observed. This was evident during observations conducted for the Medication Storage Task. (Francis Unit) The findings are: The facility policy titled Medication-Storage and Expiration of Multi-Dose Vials dated (MONTH) (YEAR) documented when the nurse opens any of these vials, he/she will document the date of opening and initial on the vial. An observation of the medication room on The(NAME)unit was conducted on [DATE] at 6:10pm. One opened, undated vial of [MEDICATION NAME] was observed. The medication Licensed Practical Nurse (LPN) #1 working from 5PM to 9:30PM was interviewed and stated that all nurses are responsible for checking insulin and it should be checked when you come on. The LPN also stated that insulin should be dated once opened and it would be checked before giving to ensure that it was dated. The LPN further stated that she had not been informed that there was a problem with the insulin when she assumed responsibility for the unit. On [DATE] at 07:11 PM, LPN #2 was interviewed and stated that narcotics are checked when relieving the outgoing nurse. The LPN also stated that although he assumes responsibility for both units at 3pm, he does not check the insulin because he does not use it on the(NAME)Unit. On [DATE] at 03:36 PM, the Director of Nursing was interviewed and stated that insulin vials are checked to see if anything is expired on ce a week by the night nurse. The DNS also stated that nurses are responsible for checking insulin before it is given. 415.18(d)

Plan of Correction: ApprovedMay 8, 2018

F 761
I. Immediate Corrective Action:
1)On 3/6/18 the LPN responsible for not dating the insulin vial was counseled about this by phone. The LPN no longer works at the facility.
2)On 3/6/18 a new insulin vial was ordered from pharmacy and dated when opened.
II. Identification of Others:
1) On 3/6/18, all insulin vials were checked to ensure compliance with proper labeling.
2) The facility respectfully states that all other insulin vials were labeled in accordance with currently acceptable professional principles.
III. Systemic Changes:
1) The DNS and Pharmacy Consultant reviewed and revised the facility P/P for the labeling of biologicals. Nursing staff received re-in servicing on the Policy and Procedure. Highlights of the lesson plan include:
? The requirement of labeling biological vials when opened.
? The number of days a biological vial can remain opened and used.
? The responsibility of the nurse administering the insulin to check that the vial is dated if opened.
? The measures the nurse must take when he/she finds an opened undated insulin vial.
? The addition to the policy of the responsibility of the 11-7 nurse to check the labeling of opened insulin vials each night.
? The new measure that opened vials of insulin will now be stored in the medication cart.
IV Quality Assurance:
1) An audit tool was developed to monitor compliance with the labeling of biological vials.
2) Audits will be daily by the 11-7 nurse. X 12 months.
3) Findings of the Audits will be brought to the morning meeting for follow up actions when indicated. Data analysis from the audits will be reviewed by the QA Committee on a quarterly basis for one year.
V. Persons responsible for this Ftag:
DNS, Pharmacy Consultant

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that the unit physician reviewed and followed up on the resident's entire plan of care. Specifically, there was no documented evidence of follow-up on recommendations of the ophthalmologist to acquire a prosthesis for a visually impaired resident. This was evident for 1 resident out of a Sample of 18 residents. (Resident # 2). The findings are: Resident # 2 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 03/06/18 at 10AM, the resident was observed seated in bed watching television. The right eye socket was sunken with no prosthesis and the resident was peering over the lens of the left side of the eyeglasses to see the State Agent. During an interview on 03/06/18 at 10:14 AM, the resident stated the glasses are no good. I don't go to Bingo much because I can't see too good. I can't see to knit. I told them. The Annual Minimum Data Set 3.0 dated 12/15/17 documented intact cognition, impaired vision with corrective lenses, and extensive assistance of staff with Activities of Daily Living (ADL's). The Comprehensive Care Plan Alteration in Vision dated 3/12/17 documented the following interventions: maintain safety measures, observe and address signs or complaints of eye discomfort, refer to Ophthalmologist, Optometrist or vision specialist as needed. The Optometry Consult dated 4/25/17 documented that resident is monocular (has one eye) and all the resident's ocular conditions will be monitored by the ophthalmologist. The Ophthalmology Consultation Request and Report dated 4/10/17 documented: Initial eye exam. Monocular pt. Lost R eye sec to infection; lost prosthesis as well. Should be fitted for new prosthesis OD (right eye), F/U (follow-up) Q (every) 6 months. The Ophthalmology Consultation Request and Report dated 10/2/17 documented: Does not like her glasses, lifting LU (left upper) lid improves her vision. [DIAGNOSES REDACTED] LU (left upper) lid. Should have the left upper eyelid taped to the forehead for better vision at distance. Should have a R (right) prosthesis. RTC (return to clinic) 6 months. Review of the physician progress notes [REDACTED]. There was no documented evidence that recommendations of the consultant were addressed by the physician during follow-up visits with the resident. On 03/08/18 at 11:03 AM, Registered Nurse (RN) #2 was interviewed and stated that the resident will only attend Bingo from time to time. The RN also stated that the resident did not complain to her about the eyeglasses. The RN further stated that she does not review the consults as this is done by the nurse who does the care plans and the medical secretary. The medical secretary or the Director of Nursing will let us know if there is a consult that needs to be followed up on. On 03/08/18 at 12:19 PM, the Medical Secretary was interviewed and stated that appointments for consultation are made whenever the physician makes the request. The Medical Secretary did not recall any additional referrals for the resident and reviewed the Doctors Visit binder which documented that the resident was seen by the Ophthalmologist in (MONTH) and (MONTH) (YEAR) and is next scheduled to be seen in (MONTH) (YEAR). On 03/08/18 at 03:13 PM, an interview was conducted with the Director of Nursing (DNS) who stated that she reviews most of the consults, especially the psychiatric consultations. The DNS also stated that she is aware that the resident has difficulty with vision and does not knit as much as before. The DNS further stated that she makes sure that the physician looks at all the consults and is not sure what the physician's feelings were about the resident's Ophthalmology consults. On 03/08/18 at 03:56 PM, an interview was conducted with the Attending Physician who stated that she was aware that the resident had only one eye and was not sure why she did not have any references to visual acuity evaluations in her notes. The physician also stated that when meeting with the residents she discusses the resident's pertinent concerns and if there is no reference to the Ophthalmologist the resident must not have had concerns at the visits so it was not discussed or followed up on. The physician further stated that she is sure the consultation was reviewed even though it is not documented in the notes. 415.15(b)(2)(iii)

Plan of Correction: ApprovedMay 8, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F 711
Immediate Corrective Action:
Resident # 2
1)On 4/6/18 the MD met with resident #2 to review her wishes for an eye prosthesis. The resident accepted having a prosthesis made at this time.
2)On 4/10/18 the optometrist re-evaluated resident #2 and made an adjustment to the glasses with which the resident verbalized being satisfied.
3)On 4/6/18 the MD offered Resident #2 the possibility tape to the left eye to improve visual function and the resident declined.
4)On 4/11/18 the Recreational Therapist met with resident #2 to review preferences regarding recreational activities.
5)On 4/10 and 4/11 the respective care plans for Resident #2 were all updated by the IDT.
6)Resident #2 has an appointment on (MONTH) 19th for eye prosthesis evaluation.
II. Identification of Others:
1) The facility respectfully states that there are no other residents that would require an eye prosthesis
2) On (MONTH) 6, (YEAR), a chart audit was done on all residents that had an order for [REDACTED].
III. Systemic Changes:
1) The DNS and Medical Director will review and revise the Policy and Procedure for Resident Consults. The Policy will be revised to require that the PMD document in the medical record regarding recommendations made by Consultants. An in-service for all the Medical Doctors and Members of the IDT will be to review the revised Policy. Highlights of the lesson plan include:
? The responsibility of the Physician to review all consults.
? The responsibility of the physician to discuss the recommendations with the resident.
? The responsibility of the physician to provide the resident with education regarding the risk and benefits associated with the Consultants recommendations as applicable.
? The responsibility of the Physician to document the follow up actions that are to be taken based on resident /representative goals for care.
IV Quality Assurance:
1) An audit tool will be developed to monitor Physician Compliance with reviewing Consults each resident?s total program of care during monthly Physician visits.
2) Audits will be done on all residents that are seen by a Medical Consultant monthly x 12 months.
3) Findings of the audits that need immediate correction will be brought to the DNS.
4) Data analysis from the audits will be reviewed by the QA Committee on a quarterly basis x 1 year.
V. Persons responsible for this F tag:
Medical Director, DNS, and Nurse Accompanying MD

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Recertification and Abbreviated Survey, the facility did not ensure that Advanced Directives services were provided. Specifically, there was no evidence that staff periodically reassessed a resident's decision-making capacity and desires regarding Advanced Directives. This was evident for 2 of 2 residents reviewed for Advanced Directives out of a Sample of 18 residents. (Resident # 16 and #2). The facility Policy and Procedure titled Do Not Resuscitate (DNR) dated 5/10 documented the interdisciplinary care planning team will review advanced directives during quarterly medical record review and annual care planning sessions to determine if the resident wishes to make changes in such directives. The findings are: Resident #16 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Do Not Resuscitate (DNR) Combined Consent and Documentation Form was signed and dated by the Attending Physician on 1/17/17. Review of the Order Summary Report dated 2/9/18 documented DNR. There was no Comprehensive Care Plan that addressed Advanced Directives. Review of the Social Services Notes dated 1/18/17, 6/1/17, 10/5/17 did not document that Advanced Directives had been reviewed or revised with the resident. Resident # 2 is an [AGE] year-old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Do Not Resuscitate (DNR) Combined Consent and Documentation Form was signed and dated by the Attending Physician on 3/9/17. Review of the Order Summary Report dated 2/5/18 documented Non- Hospital DNR. There was no Comprehensive Care Plan that addressed Advanced Directives. Review of the Social Services Notes dated 3/9/17 did not document that Advanced Directives had been reviewed or revised with the resident. The facility did not ensure that advance care planning was part of the facility's comprehensive care planning process and that re-evaluation of the resident's desires was done on a routine basis. On 03/08/18 at 12:42 PM, an interview was conducted with the Director of Social Work (DSW) who stated that Advanced Directives are reviewed with the resident on admission. The DSW also stated she not aware of the regulations regarding Advanced Directives and had not been doing any re-evaluation with the residents. The DSW further stated that she believes care plans for Advanced Directives are done by nursing as she was never asked to do it. On 03/08/18 at 03:42 PM, an interview was conducted with the Administrator who stated that Advanced Directives are the responsibility of the Social Worker. The Administrator also stated that Advanced Directives should be done on admission and reviewed maybe annually thereafter. 415.3 (e) (2)(iii)

Plan of Correction: ApprovedMay 8, 2018

F 578
I. Immediate Corrective Action:
Resident # 2 and #16
1)On 3/10/18 the MDS nurse developed a care plan to address Advanced Directives for resident #2.
2)On 3/10/18 the MDS nurse developed a care plan to address Advanced Directives for resident #16
3)On 4/12/18 the Social Worker met with resident #2 and provided education regarding Advanced Directives. The resident wished to continue the DNR.
4)On 4/12/18 the Social Worker met with resident #16 and provided education regarding Advanced Directives. The resident wished to continue the DNR.
II. Identification of Others:
1) As of 4/11/18 the MDS RN reviewed Advance Directives for all residents and ensured that they had a Comprehensive Care Plan addressing same.
III. Systemic Changes:
1) The Social Worker, DNS, and administrator in conjunction reviewed the facility P/P for Comprehensive Care Planning specific to Advanced Directives.
Members of the IDT will be in-serviced on care planning specific to advanced directives the lesson plan will focus on:
? The need for the RN/Social Worker to provide education to resident/representative on Advanced Directives during the Admission Process.
? The responsibility of the Social Worker to provide education to the resident/representative on a quarterly basis and/or with a significant change in condition as needed.
? The responsibility for the Social Worker/RN to initiate a Comprehensive Care Plan addressing Advanced Directives for all residents.

IV Quality Assurance:
1. An audit tool will be developed to monitor facility compliance with developing a care plan specific to advanced directives.
2) Audits will be done in conjunction with the resident?s admission, quarterly, and significant change comprehensive assessments for 12 months.
3) Findings of the audits that need immediate correction will be addressed by the Social Worker. Data analysis from the audits will be reviewed by the QA Committee on a quarterly basis for one year.

V. Persons responsible for this Ftag:
Social Worker, DNS, MDS Coordinator

FF11 483.21(b)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: §483.21(b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (i) Meet professional standards of quality.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 9, 2018
Corrected date: May 10, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on staff interview and record review conducted during a recertification survey, the facility did not ensure that services provided met professional standards. Specifically, comprehensive care plans were created and revised by a Licensed Practical Nurse (LPN). This was evident for 14 of 18 sampled residents. (Resident # 19, #6, #29, #16, #21, #2, #18, #27, #3, #15, #10, #7, #25 and # 12). The 1/31/13 New York State Education Department Office of the Professions Differentiated Scope of Practice for Licensed Practical Nurses (LPNs) included that Section 6902 of Article 139 of the Education Law distinguishes between the legal definitions of Registered Nurses (RNs) and LPNs. Section 6902, does not include nursing [DIAGNOSES REDACTED]. Thus, Licensed Practical Nurses in New York State do not have assessment privileges; they may not interpret patient clinical data or act independently on such data; they may not triage; they may not create, initiate, or alter nursing care goals or establish nursing care plans. The findings are: During the record review of multiple resident care plans for varying care areas, it was observed that these documents had been created or revised by a Licensed Practical Nurse. The facility did not ensure that services provided met professional standards and that care plans were created and revised by a Registered Nurse. On 03/09/18 at 01:03 PM, an interview was conducted via telephone by the Licensed Practical Nurse (LPN) #3 who stated that she was no longer employed by the facility as of 2/28/18. The LPN stated that she had been doing CCPs at the facility since (YEAR), and would sometimes work with the RN. The LPN also stated that she would work independently on the care plan areas she was familiar with. The LPN stated that she knows she can update care plans but cannot start them and was unaware that working on care plans was outside of the scope of practice of an LPN. On 03/09/18 at 03:36 PM, an interview was conducted with the Director of Nursing (DNS) who stated that care-plans should be done by an RN and that is why there is now an RN responsible for competing care plans. The DNS also stated that it was her understanding that LPN's can participate in care plans and that it was something they could do. 415.11 (c) (3)(i)

Plan of Correction: ApprovedMay 8, 2018

F 658
I. Immediate Corrective Action:
Residents: #19 #6 #29 #16 #21 #2 #18 #27 #3 #15 #10 #7 # 25 #12
1)On (MONTH) 14 and 15, (YEAR) residents #19 #6 #16 #21 #2 #18 #3 #15 #10 #7 #25 and #12 had their care plans reviewed by an RN same was documented in the medical record.
The facility respectfully states that resident #29 passed away on 12/31/17. Resident #27 was discharged to home on (MONTH) 30, (YEAR).
II. Identification of Others:
1)The MDS RN obtained a listing of all the residents who had a care plan review within the past 90 days in order to review them.
2) Any revisions or corrections will be made by the RN.
III. Systemic Changes:
1) The DNS reviewed the Policy and Procedure for Comprehensive Care Plans specific to the RN?s responsibility for initiation and revision of care plans. All members of the IDT received in-service on the revised policy. Highlights of the in-service include:
? The professional standards of quality specific to the development of the Comprehensive Care Plan
? The specific care plan areas that are assigned to each discipline.
? The responsibility of the RN and the IDT in creating and revising care plans.
IV Quality Assurance:
1) An audit tool will be developed to monitor compliance with care plans being initiated and revised by the RN.
2) Audits will be done on all Admission, Annual and Significant Change Assessments x 12 months.
3) Findings of the audits that need immediate correction will be brought to the attention of the DNS.
4) Data analysis from the audits will be reviewed by the QA Committee on a quarterly basis for one year.
V. Persons responsible for this F tag:
MDS RN

Standard Life Safety Code Citations

K307 NFPA 101:HVAC

REGULATION: HVAC Heating, ventilation, and air conditioning shall comply with 9.2 and shall be installed in accordance with the manufacturer's specifications. 18.5.2.1, 19.5.2.1, 9.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: March 19, 2018
Corrected date: May 15, 2018

Citation Details

NFPA 90 A, Standard for the Installation of Air Conditioning and Ventilating Systems- refers to NFPA 80, Standard for Fire Doors and Other Opening Protective. Section 19.2.3.2 states that the damper access panel shall be labeled with the words Fire Damper in letters not less than 1 inch (25 mm) in height. This standard is not met as evidenced by: Based on observation and staff interview during the recertification survey on 3/19/2018, it was determined that the facility had installed fire/smoke dampers in the ceilings/walls. The access doors to the dampers lacked identification labels with the words Fire Dampers in letters not less than 1 inch in height, as per NFPA 80. On (MONTH) 19, (YEAR) at approximately 3:00 PM, the facility's Director of Maintenance stated that access doors to all dampers, will be labeled with appropriate words,as per NFPA 80A. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 90A 2010 NFPA 80

Plan of Correction: ApprovedApril 9, 2018

Damper access panels shall be labeled with the words Fire Damper in letters not less than 1 inch (25 mm) in height as per NFPA 80.
Inspection of damper access panels for proper labeling will be added to our annual fire damper inspection log.
This will be corrected by (MONTH) 15, (YEAR). The Director of Maintenance will be responsible for ensuring compliance.

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: March 19, 2018
Corrected date: May 15, 2018

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by a automatic sprinkler system in accordance with section 9.7. Reference is made to the lack of sprinklers or obstructed sprinklers in a number of areas in the building. Examples include: the recessed alcove space in the general storage room #E16, the obstructed sprinkler in the boiler room, and the large canopy attached to the building at the first floor level. The findings include: On (MONTH) 19, (YEAR), between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that a number of areas in the building, including the following, lacked sprinklers coverage in accordance with NFPA 13: (1) In the general storage room #C16, a large alcove area used for storage lacked sprinkler coverage. The existing sprinkler in the vicinity of the storage alcove, was not located at least one-half of the distance between the sprinklers installed in the storage room. The sprinkler was located approximately 10 feet from the farthest wall in the alcove, instead of 6 feet from the wall, as per 8.6.3.2. (2) In the boiler room, at least one sprinkler was obstructed by the horizontal structural beams so as not to provide coverage for the entire protected areas. (3) At the first floor level, a large exterior canopy (measuring approximately 5 feet x 50 feet) was noted attached to the building. The canopy was constructed of a soft plastic-like material. The facility's Director of Maintenance stated that the plastic-like material of the canopy was probably combustible material. The canopy lacked sprinklers and the facility had no documentation to show that the canopy was constructed with non- combustible material so as to meet the exception rule, as per 8.15.7. (4) In the boiler room, the unsupported horizontal length between the end sprinkler and the last hanger on the 1 inch sprinkler pipe exceeded the maximum allowed length of 36 inches. The unsupported length between the end sprinklers and the last hanger was approximately 4 feet. On (MONTH) 19, (YEAR), at approximately 1:00 PM, the facility's Director of Maintenance stated that the facility will ensure that all areas are provided with sprinklers in accordance with NFPA 13. The Director further stated that the exterior canopy on the first floor will be constructed with the noncombustible material. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13

Plan of Correction: ApprovedApril 18, 2018

1. An additional sprinkler will be added in the general storage room #C16, to ensure coverage of the large alcove area used for storage as per 8.6.3.2 /NFPA 13. This will be added to the record of sprinkler inspection (log).
2. In the boiler room, the sprinkler that was obstructed by the horizontal structural beams will be adjusted (lowered) in order to ensure compliance with NFPA 13 standards. After examination, there are no additional sprinkler heads obstructed in this area. This will also be added to the record of sprinkler inspection.
3. At the first floor level, the large exterior canopy (measuring approximately 5 feet x 50 feet) constructed of a soft plastic-like material will be replaced with non- combustible material so as to meet the exception rule, as per 8.15.7. After examination, there are no other combustible canopies attached to the building.
4. In the boiler room, a support hanger will be added to the unsupported horizontal length between the end sprinkler and the last hanger on the 1 inch sprinkler pipe which exceeds the maximum allowed length of 36 inches. This will be added to the record of sprinkler inspection.
5. An inspection of the entire facility will be done to ensure that the facility meets all NFPA 13 standards for sprinklers.
6. A record of this work and log of inspection will be kept to ensure compliance.
All of the above will be completed by (MONTH) 15, (YEAR). All of the above will be assured by the Director of Maintenance.