Quantum Rehabilitation and Nursing LLC
August 29, 2016 Certification Survey

Standard Health Citations

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that an infection control program to help prevent the development and transmission of disease and infection was maintained. This was evident for one of three Stage 2 sampled residents reviewed for pressure ulcers (P/U) in a Stage 2 sample of 26. Specifically, during a wound care observation for Resident #138, the Registered Nurse (RN) failed to practice hand hygiene after cleansing the P/Us and prior to applying a clean dressing. The RN also placed a soiled dressing directly on the resident's sheets without placing a barrier beneath it. The finding is: Resident #138 had [DIAGNOSES REDACTED]. The Admission Minimum Data Set (MDS) assessment dated [DATE] documented that Resident #138 had no speech, could rarely/never be understood and rarely/never understands. The resident had short term and long term memory problems and had severely impaired cognition. The MDS documented that Resident #138 was dependent on 2 staff members for bed mobility, transfer, toilet use and bathing. The MDS further documented that the resident had an indwelling catheter and was always incontinent of bowel. The MDS documented that the resident was at risk for pressure ulcers and had a Stage 1 or greater, unhealed Pressure Ulcer on admission. physician's orders [REDACTED]. On 08/26/2016 an observation of wound care for Resident #138 was made, between 9:50 AM and 10:30 AM. The resident was positioned on the right side with the sacral/coccyx wound visible. The wound was observed to have a mild odor, was observed to be a deep crater with pink tissue and yellow slough throughout. The wound care nurse stated she had cleansed the sacral /coccyx wound, with Normal Saline (NS). The RN was observed to change her gloves and proceeded to pack the resident sacral/coccyx wound with saline moist gauze. The RN then removed her gloves, donned clean gloves and proceeded to place another gauze pad over the wound and to cover the wound with dry dressing and tape. The RN was then observed to remove her gloves and wash her hands. The RN wound care nurse proceeded to don clean gloves and assist in repositioning Resident #138 on the left side. The right hip wound was observed with firm dark brown eschar center, and yellow slough surrounding the wound. The RN wound care nurse donned clean gloves, cleansed the Right Hip wound with normal saline soaked gauze and then applied wet/moist gauze and clean protective dressing with the same gloved hands. The RN then discarded the gloves and washed her hands. Following the wound care to the Right Hip, the RN wound care nurse assisted in repositioning Resident #138 back to the right side. In the process of repositioning the resident the sacral/coccyx dressing became dislodged. The RN was observed to don clean gloves and remove the sacral/coccyx dressing, which was observed to have a moderate amount of red/yellow drainage. The RN placed the soiled dressing on the resident's bed directly on the sheets, next to the resident's pillow. The RN was observed to then repack the resident's sacral/coccyx wound with saline moist gauze and apply a clean dressing. The RN then changed her gloves and applied saline moist gauze to the inner buttock wounds and then applied another gauze pad to the sacral/coccyx wound. The RN applied a clean dressing to both areas. The RN then removed her gloves and assisted to reposition Resident #138. The RN was interviewed immediately following the treatment and stated that she should not have placed the soiled dressing on the resident's bed. The RN acknowledged that she should have washed her hands after cleansing the right hip wound, sacral/coccyx wound and R inner buttock wound prior to donning gloves and applying the clean treatment. A facility Policy titled Treatment Administration: Dressing and Wound Care dated (MONTH) (YEAR) documented steps including but not limited to: #4. Discard soiled dressing into bag; #10. Cleanse wound with prescribed solution, going from the center to the periphery .; #11. Remove gloves, discard into bag and wash hands; #12. Put on sterile gloves, if necessary; #13. Apply medication/ointments as ordered. The Director of Nursing Services was interviewed on 8/29/16 at 9:00 AM and acknowledged that the RN wound care nurse should have washed her hands after cleaning a wound and before donning clean gloves. The Assistant Director of Nursing Services was interviewed on 8/29/16 AM at 10:05 AM and stated that the RN wound care nurse had received education and a review of the facility's policy and procedure for wound care. 415.19(a)(1-3)

Plan of Correction: ApprovedSeptember 22, 2016

A. 1. Resident #138 were not affected by this deficient practice.
B. 1. All wound care residents have potential to be affected by this deficient practice.
2. The RN wound care nurse was immediately in-serviced on infection control procedures when doing wound care treatments. 8/29/16
C. 1. The In-Service Educator initiated in-service to all Registered Nurses and the Licensed Practical Nurses on infection control and the requirement of Nurses to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. 8/29/16
2. The DNS/Designee will perform treatment audits on 25% of nurses on a monthly basis.
3. The DNS/Designee will report these findings to the Administrator on a monthly basis.
D. 1. The DNS/Designee will report findings at the quarterly QA meetings.
E. 1. The DNS/ Designee is responsible for correction of this deficiency.

FF09 483.75(l)(1):RES RECORDS-COMPLETE/ACCURATE/ACCESSIBLE

REGULATION: The facility must maintain clinical records on each resident in accordance with accepted professional standards and practices that are complete; accurately documented; readily accessible; and systematically organized. The clinical record must contain sufficient information to identify the resident; a record of the resident's assessments; the plan of care and services provided; the results of any preadmission screening conducted by the State; and progress notes.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the medical records did not contain complete and consistent documentation of medication administration doses in accordance with accepted professional standards. This was evident for 5 of 8 residents reviewed for Unnecessary Drugs in a total Stage 2 sample of 26 residents (Residents # 199, 28, 36, 43 and 20). Specifically, 1) Resident # 199 received multiple doses of insulin for blood sugar (BS) results without consistent documentation in the Medication Administration Record (MAR) of the actual dosage administered. 2) Resident # 28 was administered insulin from an individualized Insulin Sliding Scale without documentation of the actual dosage administered and 3) Resident #36 had 22 days of insulin treatment without documentation of the doses administered since the time of his admission in (MONTH) (YEAR). The findings include but are not limited to: 1) Resident # 199 has [DIAGNOSES REDACTED]. The resident was admitted to the facility for short term rehabilitation on 8/10/16. The Physician's (MD) orders dated 8/10/16 documented that the resident was to be administered [MEDICATION NAME] (Insulin) 100 unit/milliliter (ml) injected per subcutaneous route per prescriber's instructions. The MD order further documented that the Insulin dosing requires individualization and included the following Protocol: Insulin Sliding Scale If BS= 60-150=0 Units, 151-200=2 Units, 201-250= 4 Units, 251-300=6 Units, 301-350=8 Units and 351-400=10 Units. The MAR documented on the following dates that Insulin was administered by documenting the finger stick (blood sugar) reading and site where administered only: 8/11/16-9:00 PM, 8/12/16-9:00 PM, 8/15/16-9:00 PM, 8/17/16 4:30 PM and 9:00 PM, 8/18/16-4:30 PM and 9:00 PM, 8/20/16-4:30 PM and 9:00 PM, 8/21/16-4:30 PM, 8/24/16-4:30 PM and 9:00 PM, and 8/25/16 at 4:30 PM and 9:00 PM. The actual dosage of the insulin administered was not documented on the MAR or found in the medical record. 2) Resident # 28 has [DIAGNOSES REDACTED]. The resident was originally admitted to the facility on [DATE]. The MD Monthly orders dated (MONTH) (YEAR) and (MONTH) (YEAR) included to administer Humolog subcutaneous injection according to an individualized Insulin Sliding Scale. The resident's sliding scale was as follows: 180-240=1 Unit, 241-300 2 Units, 301=350 3 Units, 351-400=4 Units. Review of the MAR for (MONTH) (YEAR) documented multiple administrations of Insulin without a documented dosage and only included sugar level and location of injection on the following dates: 7/1/16-4:30 PM and 9:00 PM, 7/5/16-4:30 PM, 7/8/16-4:30 PM and 9:00 PM, 7/10/16-4:30 PM, 7/19/16 4:30 PM and 9:00 PM, 7/20/16-4:30 PM, 7/24/16- 4:30 PM, and 7/31/15-11:30 AM.
3) Resident #36 has [DIAGNOSES REDACTED]. The Resident was admitted to the facility on [DATE]. The 14 day Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS documented that the resident received insulin injections for 5 out of the last 7 days during the assessment period. Current orders for the Month of (MONTH) (YEAR) were reviewed and included sliding scale orders for Humalog as follows: Humalog 100 unit/mL subcutaneous solution Dispensed: Humalog 100 unit/mL subcutaneous solution Inject by subcutaneous route 4 times per day before meals (ac) meals and at hour of sleep (hs) per sliding scale Protocol: If Blood Sugar: 0-150= 0 units 151-200= 2 units 201-250= 4 units 251-300= 6 units 301-350= 8 units 351-400= 10 units 401-9999-= 12 units If Blood Sugar is less than 60 or greater than 400 call the medical doctor. The Medication Administration Records (MAR) since admission, for the Months of (MONTH) and (MONTH) (YEAR) were reviewed. On 8 days in (MONTH) (7/20, 7/21, 7/22, 7/26, 7/27, 7/28, 7/30 & 7/31) and on 13 days in (MONTH) (8/2, 8/3, 8/5, 8/7, 8/9, 8/11, 8/12, 8/14, 8/15, 8/17, 8/18, 8/20 & 8/25) the actual unit dose of insulin administered was not recorded on the MAR. Only the injection site and blood sugars were recorded. The current, undated facility Policy and Procedure for the Administration and Preparation of Insulin includes that the administration and site are to be documented on the administration record. No references are made regarding the recording of the dose of insulin administered. The Licensed Practical Nurse (LPN)/Medication Nurse was interviewed on 08/29/2016 at 12:44 PM. The LPN stated that the finger stick reading and the injection site is all that is required on the MAR because the sliding scale in noted on the MAR with the MD order. During an interview with the Assistant Director of Nursing (ADNS)/RN on 8/29/16 at 1:00 PM, the RN stated that the facility policy for administration of the Insulin on a sliding scale has been that the scale is part of the MD Orders and the nurses only need to document the reading and site of administration. 415.22 (a) (1-4)

Plan of Correction: ApprovedSeptember 22, 2016

A. 1. Residents #199,28,36,43,20 were not affected by this deficient practice.
B. 1.All diabetic residents have potential to be affected by this deficient practice.
2. All orders for insulin with a sliding scale were immediately updated in the Electronic Medical Record to require documentation of the insulin dose administered. 8/29/16
3.ProCare pharmacy updated the EMR library to require documentation of insulin dose for insulin administration in the EMR. EMR will not allow the nurses to complete the order unless the amount of insulin is documented. 8/29/16
C. 1. facility Policy and Procedure for the Administration and Preparation of Insulin has been revised to include the administration of insulin in units as per sliding scale coverage.
2. The In-Service Educator initiated education to all Registered Nurses and Licensed Practical Nurses on the revised Policy. Started 8/29/16 Completion target 10/21/16
3 The In-Service Educator initiated education to all Registered Nurses and Licensed Practical Nurses about documentation of the actual dosage of insulin units when insulin is administered from an individualized Insulin Sliding Scale Protocol. Started 8/29/16 Completion target 10/21/16
D. The DNS/ Designee is responsible for correction of this deficiency.

FF09 483.20(k)(3)(i):SERVICES PROVIDED MEET PROFESSIONAL STANDARDS

REGULATION: The services provided or arranged by the facility must meet professional standards of quality.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and staff interviews during the recertification survey, the facility did not ensure that professional standards of practice were maintained regarding documentation of medication administered to the residents with a [DIAGNOSES REDACTED]. This was evident for a total of 5 of 8 residents reviewed for unnecessary medications in a total Stage 2 sample of 26 residents.(Residents # 199, 28, 36, 43 and 20) Specifically, 1) Resident # 199 received multiple doses of insulin for blood sugar (BS) results in accordance with a facility protocol without consistent documentation in the Medication Administration Record (MAR) of the actual insulin unit dosage administered. 2) Resident # 28 was administered insulin from an individualized Insulin Sliding Scale Protocol without documentation of the actual dosage of insulin units administered and 3) Resident #36 had 22 days of insulin treatment without documentation of the insulin unit doses administered since the time of his admission in (MONTH) (YEAR). The findings include but are not limited to: 1) Resident # 199 has [DIAGNOSES REDACTED]. The resident was admitted to the facility for short term rehabilitation on 8/10/16. The Physician's (MD) orders dated 8/10/16 documented that the resident was to be administered [MEDICATION NAME] (Insulin) 100 unit/milliliter (ml) injected per subcutaneous route per prescriber's instructions. The MD order further documented that the Insulin dosing requires individualization and included the following Protocol: Insulin Sliding Scale If BS= 60-150=0 Units, 151-200=2 Units, 201-250= 4 Units, 251-300=6 Units, 301-350=8 Units and 351-400=10 Units. The MAR documented on the following dates that Insulin was administered by documenting the finger stick (blood sugar) reading and site where administered only: 8/11/16-9:00 PM, 8/12/16-9:00 PM, 8/15/16-9:00 PM, 8/17/16 4:30 PM and 9:00 PM, 8/18/16-4:30 PM and 9:00 PM, 8/20/16-4:30 PM and 9:00 PM, 8/21/16-4:30 PM, 8/24/16-4:30 PM and 9:00 PM, and 8/25/16 at 4:30 PM and 9:00 PM. The actual dosage of insulin administered was not documented on the MAR or in the medical record. 2) Resident # 28 has [DIAGNOSES REDACTED]. The resident was originally admitted to the facility on [DATE]. The MD Monthly orders for (MONTH) (YEAR) and (MONTH) (YEAR) included to administer Humolog subcutaneous injection according to an individualized Insulin sliding Scale. The resident's sliding scale was as follows: 180-240= 1 Unit, 241-300= 2 Units, 301=350= 3 Units, 351-400= 4 Units. Review of the MAR for (MONTH) (YEAR) and (MONTH) (YEAR) documented multiple administrations of Insulin without a documented dosage. The MAR only included the blood sugar level and the location of injection on the following dates : 7/1/16-4:30 PM and 9:00 PM, 7/5/16-4:30 PM, 7/8/16-4:30 PM and 9:00 PM, 7/10/16-4:30 PM, 7/19/16 4:30 PM and 9:00 PM, 7/20/16-4:30 PM, 7/24/16- 4:30 PM, and 7/31/15-11:30 AM.
3) Resident #36 has [DIAGNOSES REDACTED]. The Resident was admitted to the facility on [DATE]. The 14 day Minimum Data Set (MDS) assessment dated [DATE] was reviewed. The MDS documented the resident's cognition as being 15 out of 15, indicating the resident was cognitively intact. The MDS documented that the resident received insulin injections for 5 out of the last 7 days during the assessment period. Current orders for the Month of (MONTH) (YEAR) were reviewed and included sliding scale orders for Humalog as follows: Humalog 100 unit/mL (milliLiter) subcutaneous solution Dispensed: Humalog 100 unit/mL subcutaneous solution Inject by subcutaneous route 4 times per day before (ac) meals and at hour of sleep (hs) per sliding scale Protocol: If Blood Sugar: 0-150= 0 units 151-200= 2 units 201-250= 4 units 251-300= 6 units 301-350= 8 units 351-400= 10 units 401-9999-= 12 units If Blood Sugar is less than 60 or greater than 400 call the medical doctor. The Medication Administration Records (MARs) for the Months of (MONTH) and (MONTH) (YEAR) were reviewed. On 8 days in (MONTH) (7/20, 7/21, 7/22, 7/26, 7/27, 7/28, 7/30 & 7/31) and on 13 days in (MONTH) (8/2, 8/3, 8/5, 8/7, 8/9, 8/11, 8/12, 8/14, 8/15, 8/17, 8/18, 8/20 and 8/25) the actual unit dose of insulin administered was not recorded on the MAR. Only the injection site and blood sugars were recorded. The current, undated facility Policy and Procedure for the Administration and Preparation of Insulin includes that the administration and site are to be documented on the administration record. No references are made regarding the recording of the dose of insulin administered. The Licensed Practical Nurse (LPN)/Medication Nurse was interviewed on 08/29/2016 at 12:44 PM. The LPN stated that the finger stick reading and the injection site is all that is required on the MAR because the sliding scale in noted on the MAR with the MD order. The LPN stated that reading the blood sugar results and the sliding scale will determine the amount of insulin that was given. During an interview with the Assistant Director of Nursing (ADNS)/RN on 8/29/16 at 1:00 PM, the RN stated that the facility policy for administration of Insulin on a sliding scale has been that the scale is part of the MD Orders and the nurses only need to document the reading and site of administration. The facility Administrator was interviewed on 8/29/2016 at 11:00 AM. The Administrator stated that the EHR program is still in development. The Administrator stated that it has been the policy of the facility to document only site and blood sugar. 415.11(c)(3)(i)

Plan of Correction: ApprovedSeptember 22, 2016

A. 1. Residents #199, 28,36,43,20 were not affected by this deficient practice.
B. 1.All diabetic residents have potential to be affected by this deficient practice.
2. All orders for insulin with a sliding scale were immediately updated in the Electronic Medical Record to require documentation of the insulin dose administered. 10/21/16
3. ProCare pharmacy updated the EMR library to require documentation of insulin dose for insulin administration in the EMR. EMR will not allow the nurses to complete the order unless the amount of insulin is documented. 8/29/16
C. 1. The In-Service Educator initiated education to all Registered Nurses and Licensed Practical Nurses about documentation of the actual dosage of insulin units when insulin is administered from an individualized Insulin Sliding Scale Protocol. Started 8/29/16 Completion target 10/21/16
D. The DNS/Designee is responsible for correction of this deficiency.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

1998 NFPA 25:2-2.1.1 Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded or in the improper orientation. 1998 NFPA 25:2-4.1.4 A supply of at least six spare sprinklers shall be stored in a cabinet on the premises for replacement purposes. The stock of spare sprinklers shall be proportionally representative of the types of temperature ratings of the system sprinklers. A minimum of two sprinklers of each type and temperature rating install shall be provided. The cabinet shall be so located that it will not be expose to moisture, dust, corrosion or a temperature exceeding 100 degrees Fahrenheit (38 degrees C). 1999 NFPA 13: 5-3.1.5.2 When existing light hazard systems are converted to use quick-response or residential sprinklers, all sprinklers in a compartmented space shall be changed. Based on observation and staff interview, the facility failed to ensure that the sprinkler system was continuously maintained in a reliable operating condition. Specifically, (1) sprinklers were installed in the wrong orientation, (2) compartmented areas contained two different sprinkler types and (3) two spares of every type of sprinkler were not kept on premise. This was observed on 2 of 3 floors of the facility. The findings are: On 8/23/2016 between the hours of 9am and 2pm during the recertification survey, the following was observed: (1) In the bathroom at the nursing station on the 3rd floor, a pendant type sprinkler head was noted to be in the wrong orientation. (2) The landing of Stair 1C on the 3rd floor was noted to contain a quick response type sprinkler. The remaining sprinklers in that stairwell contained ordinary type sprinklers. (3) In the sprinkler main room on the 1st floor, spare sprinklers were observed. None of the spare sprinklers were of the quick response type. In an interview on 8/23/2016 at approximately 10:15am with the Director of Environmental Services, he stated the sprinkler appears to be new and does not know why they replaced it with a quick response head. In an interview on 8/23/ at approximately 12:30pm with the Director of Environmental Services, he stated the facility is in the process of upgrading the sprinklers and would address the sprinkler issues with the sprinkler company. 1998 NFPA 25 1999 NFPA 13 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 22, 2016

A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. 1. Director of Maintenance contacted sprinkler company (Apollo) to evaluate the affected sprinkler heads and replace with the appropriate heads.
2. Director of Maintenance/designee will conduct audits on sprinkler system to ensure automatic sprinkler system is inspected and tested periodically.
D. 1. Director of Maintenance/designee will report findings of audits to administrator on a monthly basis.
2. Administrator will report findings of this audit at the quarterly QA meetings
E. Director of Maintenance is responsible for the correction of this deficiency

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K-67 S/S=B Vertical duct penetrations which passed through the floor/ceiling assembly of the building were not enclosed in at least 1-hour fire resistance rated construction. NFPA [PHONE NUMBER] Life Safety Code: 19.5.2.1, 9-2, NFPA 90A-1999 3-3.4 10NYCRR, 415.29 (a) (2)

Plan of Correction: ApprovedSeptember 22, 2016

The facility respectfully requests a repeat waiver for the requirements for: Life Safety Code: 19.5.2.2 NFPA 90A

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Stairways and smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

2000 NFPA 101: 7.2.2.5.3* Usable Space. There shall be no enclosed, usable space within an exit enclosure, including under stairs, nor shall any open space within the enclosure be used for any purpose that has the potential to interfere with egress. This requirement is not met as evidenced by: Based on observation and staff interview during the recertification survey, the facility did not ensure that the stairway enclosure is maintained free of any storage or other usage in accordance with 7.2.2.5.3. Reference is made to storage within an emergency exit stairwell on the 1st floor. The finding is: During life safety code survey conducted on 08/23/16 at approximately 11:50am, it was noted that two medication/treatment carts and a standalone hand sanitizer dispenser were kept on the landing level within Stair A on the 1st floor. In an interview at this time, the Director of Maintenance stated that the items were not supposed to be kept within the stairwell and that he was unaware that they were kept there. He immediately removed the items when they were pointed out. NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedSeptember 22, 2016

A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. 1. Director of Maintenance removed all items stored inside stairwell A, all staff has been in-serviced on not storing items in any stairwells.
2. Director of Maintenance/designee will conduct audits on a weekly basis to ensure no stairwell is being used for storage.
D. 1. Director of Maintenance/designee will report findings of audits to administrator on a monthly basis.
2. Administrator will report findings of this audit at the quarterly QA meetings
E. Director of Maintenance is responsible for the correction of this deficiency.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture will not leave the area in darkness. Lighting system shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8, 7.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

2000 LSC 101:7.8 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 42. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use. Artificial lighting shall be employed at such locations and for such periods of time as required to maintain the illumination to the minimum criteria values herein specified. 7.8.1.3 The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1.1 shall be illuminated to values of at least 1 ft-candle (10 Lux) measured at the floor. 7.8.1.4 Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2 Lux) in any designated area. Based on observation and staff interview, the facility failed to ensure that exit doors were equipped with at least 2 light fixtures. This was observed in the 1st floor of the facility. The findings are: On 8/23/2016 between the hours of 9am and 2pm during the recertification survey, the following was observed: Designated exit doors leading to the outside of the facility were observed to be lacking the appropriate lighting fixtures. At the exit door from the Rehab Gym leading to the exterior walkway, no illuminating fixtures were present. At the Service Area exit, the area above the door was noted to contain only one light fixture. In an interview on 8/23/2016 at approximately 11:35am with the Director of Maintenance, he stated they can add extra lighting where required. 10NYCRR 711.2(a)(1) 1999 NFPA 101

Plan of Correction: ApprovedSeptember 22, 2016

A. No residents were affected by the deficient practice.
B. All residents have the potential to be affected by the deficient practice.
C. 1. Director of Maintenance installed appropriate lighting fixtures on the exit from the rehab gym and the service area exit.
2. Director of Maintenance/designee will conduct audits on a monthly basis to ensure all exits are illuminated appropriately.
D. 1.Director of Maintenance/designee will report findings of audits to administrator on a monthly basis.
2. Administrator will report findings of this audit at the quarterly QA meetings
E. Director of Maintenance is responsible for the correction of this deficiency

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Building construction type and height meets one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K-12 S/S=B The facility is a 3 story, Type II (000) construction building that is fully sprinkered. The Life Safety Code prohibits Type II (000) buildings from being more than two stories in height with complete automatic sprinkler system. NFPA [PHONE NUMBER] Life Safety Code: 19.1.6.2, NFPA 220, Standard Types of Building Construction, NFPA 13, Standard for the Installation of Sprinkler Systems 10NYCRR, 415.29 (a) (2),

Plan of Correction: ApprovedSeptember 22, 2016

Facility is going to correct deficiency for Life Safety code 19.1.6.2 NFPA 220 while awaiting waiver determination.
Facility has applied for time limited waiver and has contracted(NAME)W. Baumgarten Architect, P.C. to conduct FSES

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Automatic sprinkler system supervisory attachments are installed and monitored for integrity in accordance with NFPA 72, and provide a signal that sounds and is displayed at a continuously attended location or approved remote facility when sprinkler operation is impaired. 9.7.2.1, NFPA 72

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 29, 2016
Corrected date: October 21, 2016

Citation Details

The following requirement of the Life Safety Code has been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews, and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued, or provide a plan of correction. K-61 S/S=B The sprinkler system RPZ/water backflow prevention control valve located in an exterior vault enclosure is not provided with an electronic supervisory device. NFPA [PHONE NUMBER] Life Safety Code: 9.7.1.2.1, NFPA 13, NFPA 72 10NYCRR, 415.29 (a) (2)

Plan of Correction: ApprovedSeptember 22, 2016

The facility respectfully requests a repeat waiver for the requirements for: Life Safety Code: 9.7.2.1, NFPA 72