Elm Manor Nursing and Rehabilitation Center
February 8, 2018 Certification Survey

Standard Health Citations

FF11 483.45(c)(3)(e)(1)-(5):FREE FROM UNNEC PSYCHOTROPIC MEDS/PRN USE

REGULATION: §483.45(e) Psychotropic Drugs. §483.45(c)(3) A psychotropic drug is any drug that affects brain activities associated with mental processes and behavior. These drugs include, but are not limited to, drugs in the following categories: (i) Anti-psychotic; (ii) Anti-depressant; (iii) Anti-anxiety; and (iv) Hypnotic Based on a comprehensive assessment of a resident, the facility must ensure that--- §483.45(e)(1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; §483.45(e)(2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs; §483.45(e)(3) Residents do not receive psychotropic drugs pursuant to a PRN order unless that medication is necessary to treat a diagnosed specific condition that is documented in the clinical record; and §483.45(e)(4) PRN orders for psychotropic drugs are limited to 14 days. Except as provided in §483.45(e)(5), if the attending physician or prescribing practitioner believes that it is appropriate for the PRN order to be extended beyond 14 days, he or she should document their rationale in the resident's medical record and indicate the duration for the PRN order. §483.45(e)(5) PRN orders for anti-psychotic drugs are limited to 14 days and cannot be renewed unless the attending physician or prescribing practitioner evaluates the resident for the appropriateness of that medication.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #26) of five residents reviewed for unnecessary medications, the facility did not ensure that each resident's drug regime was free of unnecessary medications. The issues involved the lack of documentation of an adequate indication for the continued use of an antipsychotic medication. This is evidenced by the following: Resident #26 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 1/12/18, revealed that the resident's cognitive skills for daily decision making were severely impaired, received antipsychotic, and there were no behaviors documented in the look back period. In addition, MDS Assessments dated 1/26/17, 4/27/17, 7/27/17, 9/12/17, and 10/13/17 revealed no documented behaviors for the resident. The [MEDICAL CONDITION] and Gradual Dose Reduction (GDR) Tracking Sheet, dated 8/26/16, revealed that the resident's [MEDICATION NAME] (antipsychotic) was decreased to 0.25 milligrams (mg) in the evening, the morning, and as needed doses remained the same. On 10/21/16, it was documented that the resident failed the GDR taper of [MEDICATION NAME] and to resume the twice a day dose. The resident's as needed [MEDICATION NAME] was discontinued on 8/7/17. There was a notation that a medical assessment was completed on 11/10/17. The resident's behavior plan, created on 11/27/15 and reviewed on 1/26/18, revealed that the resident's behaviors included inability to sit still, restless behaviors, wandered in and out of resident's rooms, easily irritable and agitated, noncompliance with safety recommendations, and the goal was to decrease problem behaviors. Interventions included, but were not limited to, to ascertain resident's where about and safety of resident and others, redirection as needed, offer toileting, offer food, quiet time when overstimulated, and enjoys watching the birds and squirrels when sitting in the plant corridor. The Comprehensive Care Plan, dated 1/26/18, revealed that the resident had a behavior problem as evidenced by being socially inappropriate, resistive to care, and verbally and physically abusive. Approaches included using simple explanations, maintaining the resident's routines, reality orientation as needed, and praise appropriately. Review of the Nursing Progress Notes, from 8/17/17 through 2/8/18, revealed that on 8/14/17 on the day shift, the resident had increased agitation at breakfast, swearing, and hitting. The resident was more pleasant at lunch. On 8/18/17, the Certified Nursing Assistant (CNA) reported to the nurse that they attempted to shower the resident, he became combative and verbally abusive, and was swearing at the CNAs and attempting to hit them. There were no other behaviors documented during that time frame. A Physician Note, dated 11/10/17, revealed that the resident's behaviors were stable, and given the resident's history of behaviors he would not recommend a GDR now as the resident was redirectable and stable. The resident's current physician orders, dated 2/1/18, included Risperidal 0.5 mg twice a day. A Physician Note, dated 2/1/18, revealed that the resident was stable but had a slow progressive decline secondary to dementia and adult failure to thrive. The resident was tolerating [MEDICATION NAME] having no side effects (Tardive Dyskinesia involuntary repetitive body movements or extrapyramidal symptoms drug induced movement disorders), and he would consider a GDR in the future if the resident remains stable. The resident was observed on 2/5/18 at 10:59 a.m., sleeping in his bed and, at 12:30 p.m., the resident was being fed lunch. There were no verbal or physical behaviors at that time. On 2/6/18 at 11:27a.m. and 11:55 a.m., the resident was alert and was sitting in his wheelchair at the activity table. The resident was quiet and had no behaviors. On 2/8/18 at 8:30 a.m., the resident was being assisted with finishing his breakfast drink, and at 9:04 a.m., the resident was sitting quietly near the nurses' station. Interviews conducted on 2/8/18 included the following: a. At 8:38 a.m., CNA #1 said the resident can be resistive to cares in the morning when we get him up for the day. CNA #1 said he will hit, he has kicked somebody in the forehead, he will curse us, but then in the afternoon he can be a sweetheart. CNA #1 said when the resident starts acting out, she walks away and will re-approach him later. CNA #1 said that usually the resident was not too bad unless staff are providing cares. b. At 10:04 a.m., CNA #2 said the resident has had behaviors, such as being resistive to care. CNA # 2 said if the resident has behaviors, she leaves and re-approaches him later. CNA #2 said that she has provided care for the resident the last two days and he had no behaviors. She said the resident rarely has behaviors but if he does, she reports the behaviors to the nurse so they can document it in the medical record. c. At 10:50 a.m., Licensed Practical Nurse (LPN) #1, the Nurse Manager in training, said that behavior logs are completed each shift for at least a couple of weeks. She said on physician day, that information, including behavior logs, are provided to the physician for his review so that he can make a decision about the resident's medications. LPN #1 said that behavior logs are usually started with resident's when a new medication is ordered or there is a change in the medication. LPN #1 said that the resident was usually combative with cares in the morning and in the evening. She said staff should be documenting the resident's behaviors in the progress notes. LPN #1 said maybe his behaviors are minimal now. LPN #1 said that she had not received any reports of negative behaviors in some time. She said if behaviors were reported to her, she would have documented in the progress notes and addressed the behaviors with the physician. LPN #1 said that the resident was stable on the medications so she would not change anything. d. At 11:15 a.m., the unit secretary said she was unable to find the resident's behavior logs in the overflow area. e. At 11:09 a.m., the Registered Nurse, MDS Coordinator said that the physician will round with the nurses. She said during a routine visit, the physician will review medications and any psych recommendations. f. At 12:40 p.m., the Director of Nursing (DON) said that the resident's behavior now includes yelling and swearing and before that he used to have physical behaviors. The DON said she would entertain the idea of a GDR. g. At 1:00 p.m., LPN #2 said she used to work the evening shift, and the resident had no behaviors in the evening for months. LPN #2 said that she currently works the day shift, and the resident does not have any behaviors. h. At 1:29 p.m. by telephone, the physician said that the resident was combative and aggressive and had a history of [REDACTED]. He said the resident was harmful to self and others and there was concern for his adjustment. The physician said the resident was now stable and comfortable, and on the lowest dose possible for [MEDICATION NAME]. (10 NYCRR 415.12 (l)(1))

Plan of Correction: ApprovedMarch 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action
Resident #26 was immediately seen and evaluated by the Medical Provider and resident was found to be stable with no changes made to the MAR indicated [REDACTED]
? Team Leaders/Nurse Managers will document monthly in resident medical record their response to the [MEDICAL CONDITION] drug use
? Documentation to include;
o [MEDICAL CONDITION] drug for use, dose and frequency
o Behaviors exhibited and documented
o Non-pharmacological interventions used and outcome of intervention
o If no behaviors found, then it should be documented as such, as ?no behaviors this month?
o Medical Provider to be notified of increase or decrease in target behavior(s)
Identification of Others
The Director of Nursing/Nurse Educator or designee will audit all medical records to ensure that all other orders for [MEDICAL CONDITION] medication are compliant with the new policy and procedure. Any negative findings will be corrected immediately.
Systemic Changes
The Administrator and Director of Nursing reviewed the deficiency and the policy for [MEDICAL CONDITION] Medication. Changes made to the policy include;
? Team Leaders/Nurse Managers will document monthly in resident medical record their response to the [MEDICAL CONDITION] drug use
? Documentation to include;
o [MEDICAL CONDITION] drug for use, dose and frequency
o Behaviors exhibited and documented
o Non-pharmacological interventions used and outcome of intervention
o If no behaviors found, then it should be documented as such, as ?no behaviors this month?
o Medical Provider to be notified of increase or decrease in target behavior(s)
Quality Assurance
All Nursing staff will be inserviced and educated on the updated policy and procedure for [MEDICAL CONDITION] Medications.
The Director of Nursing will create an audit tool to be conducted by the Nurse Manager or Designee for monthly. The result of this audit will be compiled by the Director of Nursing/Designee and presented to the Quality Assurance committee.
The Director of Nursing will be responsible for the correction of this deficiency.

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

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

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one of one potable water system, the facility did not properly establish and maintain an infections prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. Specifically, the facility did not complete a legionella risk assessment for their potable water system. This is evidenced by the following: During the review of the facility's legionella program documents on 2/6/18, there was no documented risk assessment provided. During an interview on 2/7/18 at 9:43 a.m. when the Director of Maintenance was asked for the risk assessment, he said he was not sure about that. The Maintenance Director requested the information from the Administrator. The Maintenance Director printed the document the Administrator sent him and gave it to the surveyor for review. The document was a NYSDOH-5222 Environmental Assessment of Water Systems in Healthcare Settings form, but the form was blank. On 2/8/18 at 3:45 p.m., the Administrator stated that he was going to reach out to the previous facility owner to find out if a risk assessment had been done. On 2/8/18 at 4:25 p.m., the Administrator stated that he had not received a risk assessment from the previous ownership. (10 NYCRR Part 4 Subpart 4-2)

Plan of Correction: ApprovedMarch 4, 2018

Immediate Corrective Action
The Administrator and Director of Building Services reviewed the policy and procedure for Legionella testing and water management plan to be compliant. The Director of Building services immediately performed a Legionella Risk Assessment for the facility and found no negative results.
Identification of Others
The Facility respectfully submits that all residents were potentially affected by this deficiency.
Systemic Changes
The Administrator provided the Director of Building services with an inservice and education on F880 and for failure to follow the facility policy to perform a Risk Assessment on an annual or as needed basis. The Third Party testing company was contacted and informed that all future testing must be done once provided with Risk Assessment to ensure compliance with the regulation.
Quality Assurance
Based on the findings of the Facility?s annual Legionella in collaboration with the current Risk Assessment completed by the Director of Building Services, no negative findings were found that require additional testing at this time. An additional Risk Assessment will be completed by the Director of Building Services within 60 days to ensure compliance. The facility will then require a Risk Assessment to be completed prior to the next round of Legionella Testing. Results of the current assessment and future assessments will be compiled and presented to the Quality Assurance Committee by the Director of Building Services. Any negative findings will be addressed immediately through the policy and procedure of the Facility?s Water Management Plan.
The Director of Building Services will be responsible for the correction of this deficiency.

FF11 483.25:QUALITY OF CARE

REGULATION: § 483.25 Quality of care Quality of care is a fundamental principle that applies to all treatment and care provided to facility residents. Based on the comprehensive assessment of a resident, the facility must ensure that residents receive treatment and care in accordance with professional standards of practice, the comprehensive person-centered care plan, and the residents' choices.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #16) of five residents reviewed for unnecessary medications, the facility did not ensure the resident received treatment and care in accordance with professional standards of practice, their comprehensive person centered care plan, and the resident's choice. The issue involved failure to follow physician orders [REDACTED]. This is evidenced by the following: Resident #16 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Physician orders [REDACTED]. Review of the (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) revealed no documented weights for ten days. There was no reason for the omissions documented on the back of the MARs. There was no documentation of the weights in the progress notes. The as needed [MEDICATION NAME] was signed off as administered twice in (MONTH) (YEAR) for weights greater than 230 pounds. During an observation on 2/5/18 at 1:26 p.m., the resident was receiving oxygen and had [MEDICAL CONDITION] in both legs. Interviews conducted on 2/6/18 included the following: a. At 1:32 p.m., the Registered Nurse Educator said if treatments and medications are not signed off it means it was not done. She said the nurses are supposed to ensure that does not happen by exchanging their MARS at the end of the shift and checking for omissions. b. At 1:42 p.m., the Licensed Practical Nurse (LPN) who worked on 2/5/18, said it was an error on her part. The LPN said she believed she had written the resident's weight on her report sheet. c. At 1:58 p.m., the Director of Nursing said if the weights are not documented, then it is assumed that they were not done. (10 NYCRR 415.12)

Plan of Correction: ApprovedMarch 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action
Resident #16 was immediately seen by the Medical Provider and no adverse affects were found. The Director of Nursing reviewed the policy and procedure for Weights and updated it to include the following:
? Daily and Weekly weights will be placed on the MAR
? Nurse Managers/Supervisors will be responsible to ensure weights are obtained and transcribed on to the MAR
? Nurse Managers/Supervisors will be responsible to document daily and weekly weight on the daily staffing/assignment sheet.
Identification of Others
The Director of Nursing/Nurse Educator or designee will audit all medical records to ensure that all other physician orders [REDACTED]. Any negative findings will be corrected immediately.
Systemic Changes
The Administrator and Director of Nursing reviewed the deficiency and the policy for Weights. Changes made to the policy include;
? Daily and Weekly weights will be placed on the MAR
? Nurse Managers/Supervisors will be responsible to ensure weights are obtained and transcribed on to the MAR
? Nurse Managers/Supervisors will be responsible to document daily and weekly weight on the daily staffing/assignment sheet.
Quality Assurance
All Nursing staff will be inserviced and educated on the updated policy and procedure for Weight Orders. The LPN Nurse that failed to ensure the compliance the orders for Resident #16 will be educated appropriately for the failure to properly monitor the order.
The Director of Nursing will create an audit tool to be conducted by the Nurse Manager or Designee on a weekly basis for three (3) months. After the three months, this audit will be continued on a monthly basis for an additional 3 months to ensure compliance of daily and weekly weights.
The Director of Nursing will be responsible for the correction of this deficiency.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #20) of five residents reviewed for unnecessary medications, the facility did not provide services consistent with professional standards of quality. The issue involved an incorrect transcription of a physician's medication order resulting in the resident receiving an incorrect medication. This is evidenced by the following: Resident #20 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 12/26/17, included that the resident was cognitively intact and was receiving an antibiotic. Physician's orders, dated 12/28/17, included Acidophilus ([MEDICATION NAME] containing lactobacillus found in the digestive system) one capsule daily by mouth. Physician's orders, signed 1/18/18, included [MEDICATION NAME] ([MEDICATION NAME] containing saccharomyces boulardii lyo to provide immune support to defend against infection) 250 milligrams by mouth twice daily. The (MONTH) (YEAR) and (MONTH) (YEAR) Medication Administration Records (MARs) included Acidophilus one capsule once daily. Interviews conducted on 2/6/18 included the following: a. At 2:35 p.m., the Licensed Practical Nurse (LPN) said that the Acidophilus was ordered on [DATE] but the new order on 1/18/18 for [MEDICATION NAME] would supersede that order. She said that according to the orders, the resident should be getting [MEDICATION NAME] twice a day, but she is getting Acidophilus once a day. The LPN stated she has been told they are the same medications and can be used interchangeable but she does not believe that is true. The LPN said there is a two-check system to check physician's orders and that was not done in this case. She said the 1/18/18 physician order for [REDACTED]. b. At 3:13 p.m., the Registered Nurse (RN) Supervisor/Staff Educator said the 1/18/18 [MEDICATION NAME] order would be the current order because it was written after the 12/28/17 physician order. The RN said she was the nurse that took off the 1/18/18 order and initialed that it was the first check. She said there was no documentation that another nurse checked the orders. The RN said she has heard the pharmacist say that Acidophilus and [MEDICATION NAME] were interchangeable. The RN stated that the nurses should have been giving [MEDICATION NAME] twice a day and that she will call the physician and clarify the order. When interviewed on 2/8/18 at 9:42 a.m., the RN Supervisor/Staff Educator said she had spoken to the physician, he wanted the resident to be on Acidophilus once daily, and she wrote the verbal order. Review of the facility policy, Transcription of Physician Orders, dated 8/15/12, revealed that after orders are transcribed, the night nurse is responsible for doing a second check on all orders written to ensure they have been transcribed appropriately and make any corrections if needed. The night nurse will check the daily physician's orders and check the orders against the MAR indicated [REDACTED]. (10 NYCRR 415.11(c)(3)(i))

Plan of Correction: ApprovedMarch 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Immediate Corrective Action
Resident #20 was seen by the Medical Provider and no adverse affects were found by this error. The Director of Nursing reviewed the policy and procedure for Transcription of Physician order [REDACTED].
? New Physician order [REDACTED].
? The second order check will be completed by the alternating nurse on the same shift in which the order was written. If a new order is obtained by the night shift, it will be second checked by the day shift oncoming nurse.
? The night shift nurse will review each residents chart to ensure all physicians orders have been transcribed and second checked.
Identification of Others
The Director of Nursing/Nurse Educator or designee will audit all medical records to ensure no additional transcription errors are found. Any negative findings will be corrected immediately.
Systemic Changes
The Administrator and Director of Nursing reviewed the deficiency and the policy for Transcription of Physician Orders. Changes made to the policy include;
? New Physician order [REDACTED].
? The second order check will be completed by the alternating nurse on the same shift in which the order was written. If a new order is obtained by the night shift, it will be second checked by the day shift oncoming nurse.
? The night shift nurse will review each residents chart to ensure all physicians orders have been transcribed and second checked.
Quality Assurance
All Nursing staff will be inserviced and educated on the updated policy of Transcription of Physician Orders. The Nurses that failed to transcribe the orders for Resident #20 will be educated appropriately for the failure to properly transcribe the order.
The Director of Nursing will create an audit tool to be conducted by the Nurse Manager or Designee on a weekly basis for three (3) months. Ten (10) resident charts will be randomly selected for audit. After the three months, this audit will be continued on a monthly basis for an additional 3 months to ensure compliance of Transcription of Monthly Orders.
The Director of Nursing will be responsible for the correction of this deficiency.

Standard Life Safety Code Citations

K307 NFPA 101:BUILDING CONSTRUCTION TYPE AND HEIGHT

REGULATION: Building Construction Type and Height 2012 EXISTING Building construction type and stories meets Table 19.1.6.1, unless otherwise permitted by 19.1.6.2 through 19.1.6.7 19.1.6.4, 19.1.6.5 Construction Type 1 I (442), I (332), II (222) Any number of stories non-sprinklered and sprinklered 2 II (111) One story non-sprinklered Maximum 3 stories sprinklered 3 II (000) Not allowed non-sprinklered 4 III (211) Maximum 2 stories sprinklered 5 IV (2HH) 6 V (111) 7 III (200) Not allowed non-sprinklered 8 V (000) Maximum 1 story sprinklered Sprinklered stories must be sprinklered throughout by an approved, supervised automatic system in accordance with section 9.7. (See 19.3.5) Give a brief description, in REMARKS, of the construction, the number of stories, including basements, floors on which patients are located, location of smoke or fire barriers and dates of approval. Complete sketch or attach small floor plan of the building as appropriate.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: N/A

Citation Details

Based on observations and record review conducted during the Life Safety Code Survey, it was determined that for one (historical building) of two resident use buildings, the facility did not provide a compliant building construction type. The issue was related to the use of a non-permitted building construction type for a healthcare setting. The findings include: Observations on 2/8/18 at 9:20 a.m. revealed the interior structural supports of the historic section of the facility are comprised of wood and heavy timber. Observations in the basement (just below the occupied first floor) and attic (just above the unoccupied second floor) revealed vertical structural components of large wood timbers that were unprotected from fire. Additionally, the floor separations at the attic and basement levels were observed to be unprotected wood. Observations on the occupied (renovated) first floor and unoccupied (storage) second floor revealed the vertical structural components are covered by gypsum board and sheet rock. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.1.6.1)

Plan of Correction: ApprovedMarch 8, 2018

Immediate Corrective Action
Third Party Consultant that previously provided facility with a positive FSES assessment score was contacted to reassess the building for potential of receiving an updated positive FSES score.
Identification of Others
The facility respectfully submits that all residents were potentially affected by this deficiency.
Systemic Changes
Based on review by Third Party Consultant, it was determined that the facility will submit a Time Limited Waiver request with an anticipated expiration of 3 years. This time limited waiver will allow the facility additional time to assess the facility with architects, contractors and specialists develop a plan for physical modification of historic building or the relocation of Therapy services from the Historical section of the building. The Time Limited Waiver application will be submitted to BAER by (MONTH) 23rd, (YEAR).

Quality Assurance
Based on the review and plan developed by the Third Party Contractors and Specialists, the Director of Building Services will report the plan to the QAPI committee. The committee will review the findings for fire safety within the Historical section of the building.

The Director of Building Services will be responsible for the correction of this deficiency.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for two of two facility emergency power systems, the facility did not provide battery powered remote annunciation. Specifically, neither generator was equipped with a remote annunciator which would alert staff of an alarm condition with the generator. The findings include: On 2/7/18 at 8:46 a.m., the Director of Maintenance stated that the facility was in the process of getting a new generator company coming in with new ownership. The Director of Maintenance stated that they are aware that they need annunciator panels for the generators. He said the facility will be going forward with the annunciator for the Generac Generator, but the contractor has told them that the Kohler is too old to be able to put an annunciator panel on it. Observations on 2/8/18 at 12:33 p.m. revealed a Kohler Generator located in the outdoor generator shed and a Generac Generator located outside next to the building. A review of facility records revealed that the facility had received emails from their generator contractor that documented that the Kohler Generator was to old and could not be retrofitted with a remote annunciator. The email revealed that the contractor would be able to put a remote annunciator on the Generac Generator. No purchase offers or documentation was provided to show that the facility was committed to installing the annunciator for the Generac Generator. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 6.4.1.1.17)

Plan of Correction: ApprovedMarch 4, 2018

Immediate Corrective Action
The Administrator and Director of Building Services reviewed the deficiency. The Director of Building Services contacted alternative generator companies to review alternative option to achieve compliance for both generators. After further review, a compliant annunciator panel was found to be compatible for both generators the Third Party vendor.
Identification of Others
The Facility respectfully submits that all residents were potentially affected by this deficiency.
Systemic Changes
Professionally licensed generator company notified the facility that a compatible annunciator panel for the Kohler generator was identified. The Third Party Generator company will install both annunciator panels in collaboration with the Licensed Electrical company in 2 phases.
Quality Assurance
Inservice Training for the new remote annunciator panel will be conducted by the Director of Building Services to all staff. An audit of the functionality of the remote annunciator panel will be created by the Director of Building Services. An audit will be done weekly for 3 months to ensure compliance. Results will be collected and presented to the Quality Assurance committee.
The Director of Building Services will be responsible for the correction of this deficiency.

K307 NFPA 101:FIRE DRILLS

REGULATION: Fire Drills Fire drills include the transmission of a fire alarm signal and simulation of emergency fire conditions. Fire drills are held at expected and unexpected times under varying conditions, at least quarterly on each shift. The staff is familiar with procedures and is aware that drills are part of established routine. Where drills are conducted between 9:00 PM and 6:00 AM, a coded announcement may be used instead of audible alarms. 19.7.1.4 through 19.7.1.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

Based on interviews and record reviews conducted during the Life Safety Code Survey, it was determined that for one (night shift) of three employee shifts, the facility did not complete the required amount of fire drills. Specifically, the facility did not complete a fire drill for the fourth quarter of the calendar year (YEAR) on the night shift. The findings include: A review of facility records on 2/6/18 at 11:14 a.m. revealed that on the night shift the facility conducted fire drills on 3/23/17, 4/27/17 and 8/6/17. In an interview at that time, the Director of Maintenance stated that the night shift was from 11:00 p.m. to 7:00 a.m., and that there was no drill after 10/12/17. He said they thought that a contractor was coming to do the fire drill on the night shift, but they never showed up possibly due to the change in ownership. When asked if the facility did their own fire drill when the contractor did not show up, the Director of Maintenance stated that they did not. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.7.1.6)

Plan of Correction: ApprovedMarch 4, 2018

Immediate Corrective Action
The Administrator and Director of Building services reviewed the policy and procedure for performing fire drills on each shift at least once per quarter and found the policy to be compliant. The Director of Building services immediately performed a Fire Drill for the 11pm ? 7am shift.
Identification of Others
The Facility respectfully submits that all residents were potentially affected by this deficiency.
Systemic Changes
The Director of Building Services was counselled on K712 and failure to perform a fire drill on each shift at least once per quarter. The facility has enrolled a Third Party to oversee compliance of the coordinated internal fire drill systems. The Third Party will perform a fire drill on behalf of the facility monthly for 3 months and then on a quarterly basis thereafter.
Quality Assurance
The Third Party consultant will be responsible to perform all internal coordinated Fire Drills for 3 months and to review compliance of the performed Fire Drills performed by the Director of Building services after the 3 months for additional compliance. The Third Party consultant will provide the results of each months performed Fire Drills directly to the Administrator and Director of Building Services. Results will be compiled by the Director of Building Services and presented to the Quality Assurance Committee for 3 months for review of compliance. Any negative findings will immediately be brought will be corrected immediately.
The Director of Building Services will be responsible for the correction of this deficiency.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: February 8, 2018
Corrected date: April 9, 2018

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for one (Seneca Lane) of six exits from resident areas, the facility did not maintain exit discharge pathways. Specifically, excavation had taken place in the exit discharge pathway which left the pathway uneven. The findings include: Observations on 2/8/18 at 12:38 p.m. revealed that the egress pathway from the Seneca Lane exit door to the road was exposed dirt and very uneven. In an interview at that time, the Director of Maintenance stated that there was new plumbing installed in the late summer and they had to dig in the egress pathway. The Director of Maintenance stated that the contractor had not returned to do the final grade on the excavated area. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.6.3)

Plan of Correction: ApprovedMarch 4, 2018

Immediate Corrective Action
The Administrator and Director of Building Services reviewed this deficiency. The Third Party Vendor that performed the excavation initially was contacted to return for final grading of the egress path.
Identification of Others
The Facility respectfully submits that all residents were potentially affected by this deficiency.

Systemic Changes
The Facility will contract with the Third Party Vendor to complete the initial project and put a final grade on the exit discharge pathway with an even pathway.
Quality Assurance
Following the final grading of the egress pathway via the Seneca Lane exit door, the Quality Assurance committee will review the quality of the pathway to assure its safety compliance. Any negative findings found by the committee will be corrected by way of creating a paved path through the non-compliant section.
The Director of Building Services will be responsible for the correction of this deficiency.