Putnam Nursing & Rehabilitation Center
January 2, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, record review and interviews conducted during a recertification survey, the facility did not review and revise the comprehensive care plan for 1 of 1 resident reviewed for resident rights/exercise of rights (#12) to address the use of the call bell or tap bell to enable the resident communicate her needs or request for staff assistance when needed. The finding is: Resident #12 has [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set (MDS; a resident assessment tool) of 10/6/17 indicated that the resident's BIMS score (Brief interview For Mental Status; used to test for memory recall and orientation) was 12 out of 15 which suggested that the resident has moderately impaired cognition. This MDS further indicated that the resident was totally dependent on two persons with regards to bed mobility, transfer, locomotion, dressing, toileting and personal hygiene. The resident was interviewed on 12/20/17 at 11:10 AM and stated that she does not have a call bell and that she is unable to reach the staff when she needs assistance. At this time, the resident was in bed and there was no call bell. The space where the call bell cord that was supposed to be attached, was missing. In addition, there were no other devices within the resident's reach that she could use to call for staff assistance if needed. For three days, following this observation, on 12/21/17 at 10:21 AM, 12/22/17 at 10:15 AM, and 12/27/17 at 9:00 AM, there was no call bell or tap bell available at the resident's bedside. The resident was in bed during all these observations. On 12/27/17 at 9:30 AM, a tap bell was noted to be placed on top of an overbed table which was located across the room and was not within reach of the resident who was lying in bed. The comprehensive care plan, including but are not limited to the care plans for activities of daily living, incontinence, resistance to care plan management, and aggressive behavior, with effective date of 8/25/15 and updated on 7/26/17, did not provide documented evidence that it was revised to address how the resident would communicate her needs or provide alternative solutions when her aggressive behaviors have subsided. The Nurse Manager (#1) of the unit where the resident resides was interviewed on 12/28/17 at 12:23 PM as to why the call bell was taken away. NM#1 stated that the call bell was removed around (MONTH) (YEAR) because she tried to harm herself with the call bell cord. NM#1 stated that the resident was verbally abusive and screams at staff members. She stated that since that time, the resident did not attempt to harm herself. NM#1 stated that a tap bell was provided which the resident uses from time to time and no attempt has been made to give the call bell back to the resident. NM#2 was interviewed on 12/28/17 at 12:31 PM and stated that the resident was in her unit for approximately four years. During that period, the call bell was taken away from the resident because she was wrapping the cord around her head and saying she was going to kill herself. NM #2 stated that when given a tap bell, the resident was throwing it at them. She stated that the resident broke the television with the tap bell and it was taken away. The assigned Certified Nurse Assistant (CNA) #1 was interviewed on 12/28/17 at 2:41 PM and stated that she have never heard the resident say that she is going to harm herself for a long time. CNA#1 stated that when the resident needs help, she will call out to staff or when they go by her room she will continuously scream for help. CNA#2 was interviewed on 12/28/17 at 4:20 PM and stated that the resident can be a little combative. She stated she has never heard the resident say that she is going to harm herself. CNA #2 stated that when the resident needs assistance, she hollers or bangs on things to call the staff's attention. 415.11(c)(2)(i-iii)

Plan of Correction: ApprovedJanuary 25, 2018

F 657
1. resident #12 was immediately assessed by the Comprehensive Care Plan Team and tap bell was securely attached to the arm rest of chair when out of bed and to siderail when in bed. This will ensure that the device will always be in reach. CNA care card and CCP immediately updated. Education provided to resident. 1/16/18
2. An audit of all residents utilizing call bells was conducted and no other residents were identified as requiring tap bell.
3. Education provided by department heads to all staff on utilizing alternate methods of communication other then the conventional call bell. The Call (NAME) System Policy on use of tap bell was revised and updated. The revision states that if the resident is evaluated and not appropriate for the conventional push button wall mounted system an alternate measure will be evaluated quarterly by the comprehensive care plan team for efficacy and staff will be educated on use. (please see attached via email Call (NAME) System). 2/15/18
4. Call (NAME) System use will be evaluated upon admission, quarterly, and prn by the CCP team to determine appropriate means of communication according to individualized behaviors and needs.
Any resident who requires an alternate device for communication will be reviewed at quarterly quality assurance meetings for compliance.
5. The RN clinical care coordinator is responsible for this corrective action. 2/15/18

FF11 483.60(i)(1)(2):FOOD PROCUREMENT,STORE/PREPARE/SERVE-SANITARY

REGULATION: §483.60(i) Food safety requirements. The facility must - §483.60(i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. §483.60(i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

Based on observation and interview conducted during a recertificaiton survey, the facility did not ensure that food was stored and prepared in a manner to prevent contamination. Specifically, uncooked and undated ground beef was stored in the walk-in refrigerator in the kitchen and uncooked meat was being thawed in an unapproved manner. Foods stored in the refrigerator must be labeled and dated. Labels indicating date of removal from the freezer ensure that the item is used promptly after being thawed to prevent food-borne illness. The findings are: 1. During the initial tour of the kitchen in the morning of 12/20/17, two undated packages of ground beef, about 4-5 pounds each, were observed in the walk-in refrigerator. The Food Service Manager (FSM) was interviewed at the time and stated that they were taken out of the freezer last Thursday, 12/14/17, six days ago. 2. During a follow-up visit to the kitchen on 12/29/17, three packages of chunks of red meat were observed in two large bins containing water, each placed in a compartment of a 2-compartment sink. This was brought to the attention of the cook and informed the surveyor that the meat was being thawed to be cooked later. About three minutes later, the surveyor then showed the FSM the manner in which the meat was being thawed and stated, in the presence of the cook, that the meat should be thawed under cold running water. This is consistent with standards of practice for thawing frozen meats. The cook concurred with this and the FSM then proceeded to turn on the cold water. 415.14(h)

Plan of Correction: ApprovedJanuary 25, 2018

F 812
Immediately all food in refrigerators were inspected to ensure that they were labeled and dated, including date of removal from freezer to ensure item used timely and properly. 12/21/2017
Immediately all dietary staff were educated regarding this deficient practice. Training was provided to ensure that food would be stored and prepared in a manner to prevent contamination. The revision included a.under refrigeration that items will be dated as to when they were pulled from the freezer and labeled with a use by date not to exceed 6 days from the date pulled out of freezer. b. Under running water less then 70 degrees F. This may only be done when the running water is free to run off the item and drain. (please see attached via email Safe Food Handling Program)
Standards of practice for thawing frozen meats were in serviced. Laminated signage has been posted by food areas to provide a handy reminder on thawing in an approved manner.
1/30/2018

An audit tool was created so deficient practice does not re occur. Competency to be done with all staff by Food Service Director or designee. Competencies will be completed 4 employees monthly/first 6 months then quarterly thereafter. Competency sheet was created using the CMS Kitchen Observation Critical Pathway. This competency includes staff knowledge on proper thawing and safe food handling techniques. Results of these competencies will be brought to quarterly safety and quality assurance meetings. 2/28/18
The Food Service Manager is responsible for this corrective action. The correction will be done by 1/30/18

FF11 483.45(f)(1):FREE OF MEDICATION ERROR RTS 5 PRCNT OR MORE

REGULATION: §483.45(f) Medication Errors. The facility must ensure that its- §483.45(f)(1) Medication error rates are not 5 percent or greater;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 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 its medication error rate did not exceed 5% for 2 of 3 residents (#67 and #361) observed during a medication pass for a total of 26 observations. This resulted in a medication error rate of 7.69%. The findings are: 1. Resident #67 has [DIAGNOSES REDACTED]. A medication observation was conducted on 12/21/17 at 9:20 AM on the 2 East Unit. The Licensed Practical Nurse (LPN #1) administered medications including Vitamin B12 1,000 mcg one tablet by oral route with water to Resident #67. The current physician orders [REDACTED]. LPN #1 was interviewed on 12/21/17 at 11:00 AM and stated that she thought the resident was supposed to take the Vitamin B-12 along with the other medications with water. LPN #1 stated that she was not aware that the order stated sublingual route of administration. The Consultant Pharmacist was interviewed on 12/21/17 at 11:34 AM and stated that the reason for the sublingual route was to achieve a rapid release of the medication. 2. Resident #361 has [DIAGNOSES REDACTED]. A medication observation was conducted on the 2 West Unit on 12/21/17 at 10:27 AM. LPN #2 administered 1 teaspoon of Fiber powder with sugar in 8 ounces of water from a stock bottle. The current physician orders [REDACTED]. Review of the stock bottle revealed instructions for the orange flavored, smooth texture fiber powder dose for adults, was to administer a rounded tablespoon equivalent to 2.4 grams, which was not the same dose ordered by the Physician. LPN #2 was interviewed on 12/21/17 following review of the physician's orders [REDACTED]. LPN #2 stated that the ordered [MEDICATION NAME] with sugar 3.4 grams oral powder packet was not available. The Consulting Pharmacist (CP) was interviewed on 12/21/17 at 12:52 PM and stated that the one teaspoon dose that the nurse administered to the resident was the wrong dose which was not the same as the 3.4 grams ordered by the Physician. The CP stated that the stock label instructions included 1 tablespoon which was equivalent to 2.4 grams only.

Plan of Correction: ApprovedJanuary 25, 2018

F- 759
I. Both LPNs 1 and 2 immediately educated and provided with written counsel on Medication administration. Physicians notified and medication error reports completed.
Resident #67 was immediately assessed by the attending physician and Vit B12 lab value ordered and medication discontinued based on level within normal limit. Repeat B12 level to be completed as Physician deems necessary.
Resident #36 was assessed by attending physician with no ill effects noted from deficient practice. Resident discharged to home on 12/22/17
2. All physicians orders reviewed by pharmacy consultant to identify any other residents who may have been affected and clarified as needed

3. Education provided to all licensed nurses on medication administration. This education includes correct administration routes and doses of products.
4. Medication audit tool developed(see attached via email Medication Administration Observation) as competency for all licensed nurses administering medications. The audit tool includes correct dosage and route of administration. Audits will be completed by the pharmacy consultant, 4 nurses/monthly for the first 6 months and then quarterly thereafter. These results will be reviewed as part of the facility safety and QAPI program for compliance. 2/28/18

5. The DNS will be responsible of this corrective action to be completed by 2/28/18








FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that the designated representative (DR) of 1 of 3 residents (#161) reviewed for notification of change was promptly informed of a change in the resident's physical status. Specifically, there was no documented evidence that the DR was promptly informed of the resident's significant unplanned weight loss of 14% in one month. The finding is: Complaint #NY 223 Resident #161 was an [AGE] year old male with [DIAGNOSES REDACTED]. The resident's electronic medical record revealed that the resident's weight in pounds declined as follows: [DATE]-138 [DATE]-136 [DATE]-133 [DATE]-114 [DATE]-116 The weights from [DATE] to [DATE] represented a 14% weight loss in one month. A dietary note dated [DATE] stated that the resident had experienced a significant weight loss and that his current weight was below his ideal body weight. The note further stated that no change in intake had been reported and that the weight loss was unexplainable. The resident's DR was interviewed via telephone on [DATE] at 11:21 AM and stated that she was never informed in (MONTH) (YEAR) of the weight loss. The DR stated that she had visited the resident the third week in (MONTH) and he appeared to be OK and two weeks later on (MONTH) 3, (YEAR), when she visited the resident, she was unable to wake him up. The DR stated that the resident appeared to have lost weight at that time. The DR also stated that tests were then planned but they were not done because the resident was hospitalized on (MONTH) 4, (YEAR). (The resident expired in the hospital.) The diet technician was interviewed in the afternoon of [DATE] and provided no documented evidence that any member of the dietary staff had informed the DR of the weight loss. The other members of the interdisciplinary team were interviewed at different times as follows: - Social Worker on [DATE] at 12:55 PM, stated that she had not notified the family; - Staff Licensed Practical Nurse (LPN#3) on [DATE] at 10:15 AM, stated that she did not speak to the family about the weight loss but did speak to the family when the resident went to the hospital; - LPN Unit Manager (UM), interviewed via telephone on [DATE] at 10:28 AM, stated that he had no recollection of discussing weight loss with the family representative but discussed decline in oral intake. The UM was unable to provide documented evidence or could he recall the specific date when this conversation occurred. 415.3(e)(2)(ii)(b)

Plan of Correction: ApprovedJanuary 25, 2018

F 580
Resident #161 was discharged from the facility to hospital on (MONTH) 4, (YEAR).
Immediately an audit was conducted to identify any other resident over the last three (3) months that has the potential to be affected by a notification of change. No other residents were identified.
2/3/2018
Policy and Procedure on notification of changes was revised. The revisions were written to include, notifying when there is a change in resident's rights under Federal or State law as well as notifying when there is a change in roommate assignment.(Please see attached via email Notification Guidelines). Nursing and Social Service staff to be educated and in serviced.
2/18/2018
A tool was created to ensure that staff can demonstrate competency regarding notification of changes. This competency will address staff being able to acknowledge the circumstances on when to notify a resident/family/physician of a change in condition, notification criteria, and notification responsibilities.(Please see attached via email Competency Notification of Change)
2/18/2018
Competencies will be completed quarterly ongoing by RN Nurse Mgr./Shift Supervisor or Designee to ensure this deficient practice does not re occur. Findings will be brought to the CCP team and monthly QAPI meetings.
The director of Nursing is responsible for this corrective action 2/27/18

FF11 483.90(i):SAFE/FUNCTIONAL/SANITARY/COMFORTABLE ENVIRON

REGULATION: §483.90(i) Other Environmental Conditions The facility must provide a safe, functional, sanitary, and comfortable environment for residents, staff and the public.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

Based on observations and interviews conducted during a recertification survey, the facility did not ensure that adequate housekeeping services were provided to maintain floors in resident rooms and common areas in a clean and appealing condition. This was evident in the day/dining rooms, multiple resident bed rooms and hallways on 3 of 4 units (2 East, 2 West and 3 East). The findings are: An initial tour of the facility was conducted on 12/20/17 between 10:00 AM and 12:00 PM and the following was observed: - The day/dining rooms on the Second and Third floors exhibited scuff marks and was not shiny; - The floors in the hallway and the area in front of the elevator on the Third floor were discolored; many of the tiles were white by design and blackish and dull in appearance. The day/dining room floor on the Second Floor was cleaned and buffed on 12/21/17. Subsequent tours and observations of the facility were conducted on 12/22/17, 12/27/17 - 12/29/17 and 1/2/18. It revealed that the floors in resident rooms on the Second and Third floors were dull and in some areas exhibit streaks and scuff marks. A housekeeping staff, the head of housekeeping and the assistant head of housekeeping were interviewed on 12/29/17 between 9:15 AM and 9:45 AM. They were asked as to why the floors were not being maintained, to include stripping, application of a finish/sealant and regular buffing, to prevent them from appearing dull and unappealing. They stated that the floors were not being maintained properly and that this was due to the lack of sufficient housekeeping staff assigned to do this task. They stated that currently, the facility has only a part-time worker who is assigned to the maintenance of the floors. The housekeeping staff member assigned to maintaining the floors was interviewed in the morning of 1/2/18 and was observed cleaning and buffing the floor in the lobby area. He stated that the floors on the units were sealed with a finish last summer and that he did not work enough hours to maintain the floors as needed. 415.29

Plan of Correction: ApprovedJanuary 25, 2018

REVISION:
1. Those rooms that were identified had a cleaning schedule created. These rooms were stripped and waxed.
2. The housekeeping director completed full house environmental rounds. Rooms were scheduled based on immediate need. 50% of all rooms and common areas have now been completed. The Housekeeping staff have been reeducated to the revised 8 step program.(see attached)Programs revised to include checking floors for discoloration, dullness and the need for areas to strip and wax. Staff will notify Director of Housekeeping or assistant and then room will be placed on schedule for floor care by floor tech. The revisions include identifying floor conditions in rooms. Housekeeping staff were also educated to notify Housekeeping Director or designee if immediate floor care is needed. Laminated copies of 8 step program are secured to cart as a helpful hint sheet.
3.The Facility Environmental full house round sheets have been adapted to include floor conditions. These rounds will continue to be conducted bimonthly. Outside companies were contacted to provide hallways and common area with complete floor care.
4. Housekeeping Director or Designee will complete a QA Audit to assess the total floor care as well as other environmental observations. The audit tool was revised to include Floor care, checking for discoloration, dullness, scuff marks and if there is a need to be stripped and waxed. These audits will be completed at 5 rooms/weekly ongoing. These results will be discussed and reviewed at Quarterly Safety and Quality Assurance Meetings.
5. The Housekeeping Director and/or designee will be responsible for this corrective action. 2/27/18

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: March 26, 2018

Citation Details

2012 NFPA 101 Chapter 7 Means of Egress 7.2.2.3 Stair Details 7.2.2.3.3 Tread and Landing surfaces. 7.2.2.3.3.1 Stair treads and landings shall be solid, without perforations, unless otherwise permitted in 7.2.2.3.3.4 7.2.2.3.3.2 Stair treads and landings shall free of projections or lips that could trip stair users. 7.7 Discharge from Exits 7.7.2. Exit Discharge through the Interior Building areas. Exits shall be permitted to discharge through the interior building areas, provided that all of the following are met: (1) Not more than 50 percent of the required number of exits, and not more than 50 percent of the required egress capacity, shall discharge through areas on any level of discharge, except otherwise permitted by one of the following: (b) In existing buildings, the 50 percent limit on egress capacity shall apply if the 50 percent limit on the required number of exits is met. Based on observation and staff interview, the facility did not ensure that: 1. not more than 50 percent of the exits discharge discharge through areas on the level of discharge (ground level). Reference is made to two of three stairwells at the East and West ends of the building that discharge through the ground level corridor rather than directly to the outside. 2. Stair treads and landings that are free of projections or lips that could trip stair users. The findings are: During the recertification survey on 12/21/17, between the hours of 9:30 AM and 2:30 PM, the life safety tour was conducted and the following issues with the facility's stairwells and stairs were noted: 1. Two of three exit stairwells (East and West) discharge through the ground level corridor (lobby) rather than direcctly to the outside. In an interview at the time of the findings, the Maintenance Director stated that stairwells that discharge into the lobby were previously approved by an existing waiver. 2. Stair treads and landings were not free of projections or lips that could trip stair users. During the recertification survey on 12/21/17, between the hours of 9:30 AM and 2:30 PM,w the stair treads in three of three stairwells were noted to project over the nose of each step. In an interview at the time of the findings, the Maintenance Director stated that the stair tread and landings in the stairwells were previously approved by an existing waiver. As per records on file with the Department, the facility had undergone a change of ownership in 2014. As per 711.9, waivers or equivalencies are only in effect for the duration of the operating certificate under which they were granted. Therefore, the facility must correct the deficiencies or apply for new waivers. 2012 NFPA 101: 7.7,7.7.2 10 NYCRR 711.2 (a)(1); 711.9(a)(b)(3)(d)

Plan of Correction: ApprovedApril 18, 2018

K271 REVISION
1. A complete and thorough walk through was done of the stairwells to confirm that two of the three exit stairwells discharged into the lobby. Noted projections and lips on Stair treads and landings were also inspected
2. Due to change in ownership, the previously approved waivers were resubmitted on (MONTH) 24, (YEAR) to BAER-REJECTED. Therefore A time limited waiver for 6 months (expiration date of 8/31/2018)was requested-Waiver Number 181w034 - CMS APPROVAL NOTIFICATION received on 3/29/2018. On 4/13/2018:Submitted Notice - Construction # NOT 2385, Putnam Nursing & Rehabilitation Center, Facility ID 754. On 4/13/2018 received from DOH: Your Notice - Construction has been received by the New York State Department of Health.
Received Date: 04/13/2018
This Construction Notice had all the necessary requirements: Architect Letter of Self Certification, Safety & Move Plan, Architect Construction Drawing. At this time contractors have been interviewed and we are awaiting final bids. Contractors will be obtaining necessary permits from the Town of(NAME)and are aware of the time constraints of this project.
3. (a) In the interim: Appropriate and obvious signage was posted showing the direct path to exit. The West side stairwell is 31 feet to outside and East side stairwell is 37 feet to outside. A log was created to ensure that these pathways will be unobstructed and free from debris at all times. This log will be completed daily during maintenance designee's morning walk through.
(b) Reflective fluorescent paint was purchased and applied to emphasize the stair treads and landings to prevent stair users from tripping. The efficacy of this process will also be added to the maintenance log.
4. The results of this log will be reviewed at monthly safety meetings.
5. The maintenance director or designee will be responsible that this deficient practice does not occur again.

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

2012 NFPA 99 Health Care Facilities Code 11.6.5 Special Precautions - Storage of Cylinder and Containers 11.6.5.2 If empty and full cylinders are stored within the same enclosure, empty cylinders shall be segregated from full cylinders. Based on observation and interview, the facility did not ensure that full and empty oxygen cylinders were segregated in the garage area and in storage closets on 2 of 2 resident floors. Reference is made to stored full and empty oxygen cylinders that were not segregated. This would not ensure that an empty cylinder was not grabbed accidentally in an emergency. The findings are: During the recertification survey conducted on 12/20/17 and 12/21/18 between the hours 12:45 PM and 2:30 PM, a tour of the facility main oxygen storage area located in the garage revealed approximately 190 empty and full cylinders stored together in metal carts. Signs stating 'full' and 'empty' were not posted to indicate separate storage areas. This was also noted in the oxygen closets on 2 of 2 resident floors. In an interview at approximately 12:45 PM, the Director of Maintenance stated that there are gauges on each cylinder to differentiate which cylinder are full or empty. He further stated that full and empty signs will be posted in the oxygen closets on the resident floors and in the garage area where oxygen cylinders are stored. 2012 NFPA 99:11.6.5, 11.6.5.2 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 22, 2018

K923
1. Maintenance Director immediately contacted O2 vendor for signage and empty storage carts regarding this deficient practice of O2 storage in the garage area and storage closets. 12/20/2017
2. Signage has been posted to keep full and empty O2 cylinders separate. 12/21/2017
3. Maintenance dept. have purchased O2 holders for nursing area to ensure separation and safe storage of empty and full. 12/21/2017
4. Staff receiving ongoing in services on new policy regarding this deficient practice.1/26/2018
5. Visual checks of efficacy will be completed Daily and by bi weekly environmental rounds. Findings will be rectified immediately and discussed at monthly QAPI.


HOSPITAL CAH AND LTC EMERGENCY POWER

REGULATION: (e) Emergency and standby power systems. The hospital must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section and in the policies and procedures plan set forth in paragraphs (b)(1)(i) and (ii) of this section. §483.73(e), §485.625(e) (e) Emergency and standby power systems. The [LTC facility and the CAH] must implement emergency and standby power systems based on the emergency plan set forth in paragraph (a) of this section. §482.15(e)(1), §483.73(e)(1), §485.625(e)(1) Emergency generator location. The generator must be located in accordance with the location requirements found in the Health Care Facilities Code (NFPA 99 and Tentative Interim Amendments TIA 12-2, TIA 12-3, TIA 12-4, TIA 12-5, and TIA 12-6), Life Safety Code (NFPA 101 and Tentative Interim Amendments TIA 12-1, TIA 12-2, TIA 12-3, and TIA 12-4), and NFPA 110, when a new structure is built or when an existing structure or building is renovated. 482.15(e)(2), §483.73(e)(2), §485.625(e)(2) Emergency generator inspection and testing. The [hospital, CAH and LTC facility] must implement the emergency power system inspection, testing, and maintenance requirements found in the Health Care Facilities Code, NFPA 110, and Life Safety Code. 482.15(e)(3), §483.73(e)(3), §485.625(e)(3) Emergency generator fuel. [Hospitals, CAHs and LTC facilities] that maintain an onsite fuel source to power emergency generators must have a plan for how it will keep emergency power systems operational during the emergency, unless it evacuates. *[For hospitals at §482.15(h), LTC at §483.73(g), and CAHs §485.625(g):] The standards incorporated by reference in this section are approved for incorporation by reference by the Director of the Office of the Federal Register in accordance with 5 U.S.C. 552(a) and 1 CFR part 51. You may obtain the material from the sources listed below. You may inspect a copy at the CMS Information Resource Center, 7500 Security Boulevard, Baltimore, MD or at the National Archives and Records Administration (NARA). For information on the availability of this material at NARA, call 202-741-6030, or go to: http://www.archives.gov/federal_register/code_of_federal_regulations/ibr_locations.html. If any changes in this edition of the Code are incorporated by reference, CMS will publish a document in the Federal Register to announce the changes. (1) National Fire Protection Association, 1 Batterymarch Park, Quincy, MA 02169, www.nfpa.org, 1.617.770.3000. (i) NFPA 99, Health Care Facilities Code, 2012 edition, issued August 11, 2011. (ii) Technical interim amendment (TIA) 12-2 to NFPA 99, issued August 11, 2011. (iii) TIA 12-3 to NFPA 99, issued August 9, 2012. (iv) TIA 12-4 to NFPA 99, issued March 7, 2013. (v) TIA 12-5 to NFPA 99, issued August 1, 2013. (vi) TIA 12-6 to NFPA 99, issued March 3, 2014. (vii) NFPA 101, Life Safety Code, 2012 edition, issued August 11, 2011. (viii) TIA 12-1 to NFPA 101, issued August 11, 2011. (ix) TIA 12-2 to NFPA 101, issued October 30, 2012. (x) TIA 12-3 to NFPA 101, issued October 22, 2013. (xi) TIA 12-4 to NFPA 101, issued October 22, 2013. (xiii) NFPA 110, Standard for Emergency and Standby Power Systems, 2010 edition, including TIAs to chapter 7, issued August 6, 2009.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

Based on documentation review and interview, the facility did not have a written plan for how it will keep the emergency power system operational during the emergency, unless it evacuates. The findings are: Documentation review of the facility's emergency preparedness plan conducted during the life safety recertification survey on 12/22/17 between 10:00 AM and 2:30 PM, revealed that the plan did not address how the facility would keep its emergency power systems operational during an emergency in order to ensure continuity of meeting the residents' and staffs' subsistence needs whether the facility decides to shelter in place or relocate internally. In an interview with the Maintenance Director that took place simultaneously with the documentation review, he described the nursing home's plan on how it will keep the emergency power system operational. However, a written plan was not included in the facility's emergency plan. In an interview at the time of the findings, the Administrator stated that she will develop a plan to include how the facility will keep the emergency power system operational during an emergency. 483.73 (d)(2)

Plan of Correction: ApprovedJanuary 30, 2018

E041
REVISION
1. A written plan for how to keep the emergency power system operational during the emergency unless evacuation has been established, and implemented into our Facility Disaster Plan. This is to include our contingency plan- we will contact local fire department - lake Carmel for use of emergency gas generators. NY State Electric and Gas Company will be notified of our situation and special needs. Peak Power Systems located in Middletown NY have been contacted and will service the facility with portable commercial gas generators if necessary. They are available 24 hours, 365 days a year.
2. Staff responsible for this practice have been in serviced on updated policy and procedure as well as revised contingency plan by the Maintenance Director 2/27/18 Maintenance Director or designee will monitor fuel usage in event of a power outage. This usage will be logged and kept in generator book found in generator room.
4. Maintenance Director or designee In preparation for Forecasted emergencies (ie snowstorm, hurricane) will contact Putnam County Emergency Services will be notified for the possible use of their equipment and services.(NAME)Oil, (our vendor) for fuel supply will be called for additional delivery prior to event.
5. Maintenance Director or designee In the event of an Forecasted Power Failure with Failure of Emergency Generator will contact Lake Carmel fire department to immediately deliver their emergency gas generator or to help with any necessary evacuation.
6. Administrator or designee at yearly Facility Assessment/Disaster Plan meeting with Department heads will review as well as at quarterly QA meetings. These plans will also be reviewed annually at our Putnam county meeting with Office Emergency management services.

maintenance director is responsible for this corrective action

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

REGULATION: Illumination of Means of Egress Illumination of means of egress, including exit discharge, is arranged in accordance with 7.8 and shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

2012 LSC 101 7.8 Illumination of Means of Egress. 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 43. 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, unless otherwise provided in 7.8.1.2.2 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified. 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 (2.2 lux) in any designated area. Based on observation and interview, the facility did not ensure that the illumination of the means of egress on resident units was installed and maintained in accordance with 7.8, as evidenced by: 1. a light fixture with only a single bulb was installed at an emergency exit near the kitchen; and, 2. the corridor lighting was controlled by manually operated light switches located at the nurse's station. When these switches were turned to the' off' position, less than the 2 candle ft. of illumination would be provided in the exit corridors. This was noted on two of two resident floors. The findings are: - On 12/20/17, at approximately 12:00 PM, during the recertification survey, a tour of the emergency exit located at the end of the corridor where the kitchen is located revealed a one bulb light fixture installed on the exterior side of the exit. The lamp post in the parking lot provides illumination to the pathway from this exit, but not from the emergency exit to the pathway. - On 12/21/17 at approximately 11:10 AM, a tour of the 3 West corridor was conducted and revealed that there were wall mounted light switches located at the nurse's station. When the switches were turned to the 'off' position, only two lights in the exit corridor remained on. Illuminiation in the corridor was measured with a light meter and was only 0.2 to 0.5. This same lighting system was noted on two of two resident floors. In an interview at the time of the findings, the Director of Maintenance stated that a second bulb fixture will be installed at the emergency exit. He further stated that he will install a cover plate to prevent the corridor lights on the units from being turned to the 'off' position. 2012 NFPA 101: 19.2.8, 7.8.1.1, 7.8.1.2.1, 7.8.1.4* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 24, 2018

K281
1. Maintenance Director purchased and installed Double bulb LED light fixtures on two of the exit doors that require the two bulbs for emergency exit lights.
2. Maintenance Department checked all emergency exit lights to ensure that this deficient practice did not exist elsewhere. 1/9/2018
3. Locking switch guards were installed on nursing unit corridor lights to ensure that a illuminated path of egress is always present 24 hours a day 7 days a week. The maintenance department have the only means of disconnecting switch locks.1/3/2018
4. Visual checks of efficacy will be completed by bi weekly environmental rounds. During weekly generator load test these lights will be checked as well so sufficient lighting is available during an emergency. Findings will be rectified immediately and discussed at monthly safety and quarterly QA meetings.
5. Maintenance Director or designee is responsible for the corrective action 1/26/2018

K307 NFPA 101:PATIENT SLEEPING ROOM DOORS

REGULATION: Patient Sleeping Room Doors Locks on patient sleeping room doors are not permitted unless the key-locking device that restricts access from the corridor does not restrict egress from the patient room, or the locking arrangement is permitted for patient clinical, security or safety needs in accordance with 18.2.2.2.5 or 19.2.2.2.5. 18.2.2.2, 19.2.2.2, TIA 12-4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not ensure that the locks on a resident sleeping room did not restrict access from the corridor side for the safety and clinical needs of the resident in accordance with NFPA 101. Reference is made to a key-operated lock installed on the corridor door of a resident's sleeping room (room [ROOM NUMBER]E5) for which staff did not possess a key necessary to open the door The findings are: During the recertification survey on 12/21/17, at approximately 11:30 AM, a tour of the 3 East unit revealed that a key-operated lock was installed on the corridor side of the door to resident room [ROOM NUMBER] E 5. This room is semi -private and a door knob with a twist lock was noted on the interior side of the door. The resident and the staff did not possess a key to open the door from the corridor side. In an interview at the time of the findings, the Maintenance Director stated that the resident room doors were recently checked to see if there were locks on the doors and this resident room was overlooked. He further stated that the lock will be removed immediately. 2012 NFPA 101: 7.7,7.7.2 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 30, 2018

K221 REVISION
1. Immediately the Maintenance director removed existing said lock on room # 3E5.12/21/2017
2. Immediately an additional audit was performed by the maintenance department to ensure that this deficient practice of locks on resident sleeping rooms does not exist. Also added to admission agreement and reviewed at resident council that this facility does not accept locking mechanisms on resident rooms.
3. Checks of efficacy to ensure no further locks are installed on any resident sleeping rooms will be completed by bi weekly Environmental rounds 1/3/2018 and ongoing.
4. Findings will be immediately rectified and discussed at monthly Safety and Quarterly QA Meetings.
5. Maintenance Director or designee will be responsible for this corrective action

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

Physical Environment 415.29. (h) (2)Ventilating, heating, and air conditioning systems. Such systems shall: (2) be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology, or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bath rooms, janitor's closets and soiled utility room or soiled linen rooms, to other parts of the facility. 713-2.21 Mechanical requirements. (d) Heating and ventilating systems. (2) . All air-supply and air-exhaust systems shall be mechanically operated. All fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in Table 8 shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates. (ii) The ventilation systems shall be designed and balanced to provide the pressure relationship shown in Table 8. Based on observations and interview, the facility did not ensure that the required minimum total air changes in resident toilets were provided as per Table 8. This was evidenced by; 1. The exhaust fans in the resident shower room located on 3 west, the training bathrooms, and the bathrooms within the day/dining rooms on 2 of 2 resident floors, and a closet on 2 west that was previously a bathroom, are operated by the wall mounted light switches for the rooms. 2. The janitor's closet in the central area of the facility lack exhaust ventilation. This configuration would ensure that the minimum of 10 total air changes per hour was provided in these areas. The findings are: 1. On 12/21/17 at approximately 10:25 AM, a tour of the shower room located on 3 West revealed that the ceiling exhaust fan was operated by the light switch for the room. This was also noted in the training bathrooms and in the bathrooms in the day room/dining rooms on the second and third resident floors and in the closet located within the day/dining room on 2 west. In an interview at the time of the findings, the Director of Maintenance stated that he will install cover plates over the light switches to ensure that the required minimum air changes are provided in the rooms mentioned. 2. At approximately 9:10 AM on 12/21/2017, a tour of the of the janitor's closet on the second floor revealed that the room lacked ventilation. In an interview ant the time of the finding, the Director of maintenance stated that there were no changes with the exhaust system in the janitor's closet from the existing waiver. 10 NYCRR 415.29 (h) (2) 10 NYCRR 711.9(b)(3)(d) 10 NYCRR 713-2.21 (d)(2)(ii)

Plan of Correction: ApprovedJanuary 24, 2018

K1310 Revision
# 1
1. Those exhaust systems that were identified were immediately secured to maintain air exchange.
2. An audit was completed by Administrator and maintenance director. All of the exhaust fans that were operated with the light switches turned on were identified.
3. Maintenance dept. to install SWITCH L(NAME)KS in those identified exhaust systems.
4. Visual checks of efficacy will be completed by bi weekly environmental rounds. All concerns will be discussed at Monthly Safety and Quarterly QA.
1/2/2018
K1310 # 2
Exhaust systems that were identified will be immediately secured to maintain air exchange.
The maintenance department under the direction of the Maintenance director will install a ventilation system to code.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on documentation review and interview, the facility did not have policies and procedures in the emergency plan describing the facility's role in providing care and treatment at alternate sites under an 1135 Waiver. The findings are: Documentation review conducted during the life safety recertification survey on 12/22/17 between 10:00 AM and 2:30 PM revealed that, although the facility had transfer agreements with other facilities and policies in place to address the potential transfer of residents, it did not have policies and procedures included in the emergency plan to provide care at alternate sites under the 1135 waiver. In an interview at the time of the findings, the Administrator stated that she will develop written policies and procedures to include the continued care and treatment of [REDACTED]. 483.73(b)(8)

Plan of Correction: ApprovedJanuary 24, 2018

E026 REVISION
1. A written plan for Staff transfer with residents during an emergency evacuation has been established, and implemented into our Facility Disaster Plan.
2. Facility transfer agreements have been updated to include staff transfer with residents in the event of an evacuation to provide care and treatment at alternate sites as well as under 1135 waiver. 1/26/2018
3. Transfer agreements: Administrator or designee at yearly Facility Assessment/Disaster Plan meeting with Department heads will review as well as at quarterly QA meetings to ensure staff transfer with residents in the event of an evacuation to provide care and treatment at alternate sites as well as under 1135 waiver. Annual E FIND Drills to be conducted along with quarterly Disaster Drills. Tabletop and outside agency drills will be conducted to ensure staff education for emergencies and evacuations ongoing.

4. On admission Sigma Care is updated with resident transfer needs. Monthly reports will be generated and reviewed at monthly safety meetings and quarterly QA for necessary updates of Facility Assessment Plan.
5. Care plan team will monitor residents needs in the event of an evacuation becoming necessary and send updated results to Administrators office for update of Facility assessment according to those needs. Ongoing
Administrator is responsible for this corrective action 2/27/18

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

2011 NFPA 25 Chapter 5 Sprinkler Systems. Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8* The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (1) Pump system procedure as follows: (a) Record the system suction and discharge pressure gauge readings (b) Check the pump packing glands for slight discharge (c) Adjust gland nuts if necessary (d) Check for unusual noise or vibration (e) Check packing boxes, bearings, or pump casing for overheating (f) Record the pump starting pressure (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). 2010 NFPA 13 Standard for the Installation of Sprinkler Systems 8.8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.8.5.2 and 8.8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Based on observation and documentation review, the facility did not ensure that the automatic sprinkler system installed in required areas was maintained in accordance with NFPA 25 and NFPA 13, as evidenced by: 1. Documentation of monthly tests of the fire pump was not provided; and 2. The sidewall sprinkler heads installed in resident closets were obstructed by wood partitions in these closets. The findings are: Documentation review and the life safety tour were conducted during the recertification survey on 12/20/17 and 12/21/17 and the following issues with the facility's automatic sprinkler system were noted: 1. Documentation of the required monthly tests of the fire pump was not provided. During the review of routine sprinkler maintenance documentation on 12/20/17 at approximately 10:30 AM, the report of the annual test of the electric motor driven fire pump was provided. However, documentation of the required monthly churn tests for this fire pump was not available. In an interview at approximately 11:15 AM that same day, the Director of Maintenance stated that the electric fire pump is inspected by the vendor quarterly, but monthly reports are not available. 2. On 12/21/17 between 10:30 AM and 2:30 PM, a tour of resident rooms revealed wood partitions installed in the closets that extended to the ceiling, obstructing the spray pattern of the sprinkler. This would not ensure sprinkler coverage on both sides of these partitions. This was noted in resident rooms on 2 of 2 resident floors. In an interview at the time of the findings, the Director of Maintenance stated that the wood partitions will be cut lower to allow sprinkler coverage to the entire closets in resident rooms. 2012 NFPA 101 2011 NFPA 25: 8.3.1.2*, 8.3.2.3, 8.3.2.8 2010 NFPA 13: 8.8.5.1.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 22, 2018

K353
1. Maintenance Director immediately contacted Sprinkler company regarding this deficient practice of non-monthly system tests. They will in service the maintenance staff on how to properly inspect the fire pump on a monthly basis. 1/24/2018
2. An audit tool was developed to ensure these monthly system tests are performed along with the quarterly vendor testing.

3. Maintenance dept. has removed all partitions in the resident closets that interfere with the spray pattern of the sprinkler heads.
1/3/2018
4. Visual checks of efficacy will be completed by bi weekly environmental rounds. Findings will be rectified immediately and discussed at monthly QAPI.


K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures 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, 7.2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 2, 2018
Corrected date: February 28, 2018

Citation Details

2012 NFPA 101 Chapter 7 Means of Egress 7.2.2.4 Guards and Handrails. 7.2.2.4 Guards and Handrails 7.2.2.4.2 Continuity. Required guards and handrails shall continue for the full length of each flight of stairs. at turns of new stairs, inside handrails shall be continuous between flights and landings. Based on observation and staff interview, the facility did not ensure that the handrails in the exit stairwells continued for the full length of each flight of stairs, in accordance with NFPA 101. Reference is made to the handrails in 3 of 3 stairwells that did not extend for the full length of each flight of stairs. The findings are: On 12/21/17, during the recertification survey, a tour of the center stairwell was conducted at approximately 10:30 AM. It was noted that the stairwell is equipped with handrails on both sides of the stairs. However, the handrails did not extend beyond the top and bottom of the last steps. The handrails ended approximately 3 inches short of the bottom step and approximately 5 inches short of the top step. This was noted in 3 of 3 stairwells. In an interview at the time of the findings, the Maintenance Director stated that the handrails were approved by an existing waiver. He further stated that additional handrails will be installed to be continuous in the stairwells. 2012 NFPA 101: 7.2.2.4.,7.2.2.4.2 10 NYCRR 711.2 (a)(1); 711.9(b)(3)

Plan of Correction: ApprovedJanuary 24, 2018

K225 REVISION
1. A thorough audit was completed with all effected stairwells assessed for the need of required guards and handrails.
2. To comply with stairwell regulations hand rails for all stairwells were measured and ordered by the maintenance director to have the extension of 12 inches for the flights and landings in 3 of 3 stairwells.2/28/2018
3. Maintenance department under the direction of the Maintenance director will install new handrails to code.
4. Completion of this installation will be reviewed at next monthly safety meeting and annually thereafter.
5. The maintenance director or designee will be responsible for this corrective action 2/28/18