Bronx Center for Rehabilitation & Health Care
May 9, 2017 Certification Survey

Standard Health Citations

FF10 483.90(i)(3):CORRIDORS HAVE FIRMLY SECURED HANDRAILS

REGULATION: (i)(3) Equip corridors with firmly secured handrails on each side; and

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observations and interviews during the recertification survey, the facility did not ensure that corridors were equipped with firmly secured handrails. Specifically: during the initial tour loose fitting handrails were observed. This was evident on 2 of 5 resident units. (Units 3 and 4). The findings are: During the initial tour of unit 3 on 5/02/17 at 10:05 am, the following was observed: The handrails located below the activities calendar was not firmly secured and was observed with sharp jagged edges. Additionally, there were loose handrails between the two elevators, between the shower room and the janitor's closet and outside of the soiled utility room. On unit 4th floor, the following was observed: There were loose handrails between rooms 410 and the supplies room, between the nursing supervisor's office and the tub room, below the activity calendar and between the soiled utility room and the soiled laundry room. The Director of Housekeeping and Maintenance Services was interviewed on 5/04/17 at 11:00 am and stated that there is a maintenance log book on each unit to be used to write down any needed repairs which is reviewed daily. Handrails should be closely monitored. 415.29

Plan of Correction: ApprovedJune 5, 2017

The facility will ensure that corridors are equipped with firmly secured handrails.
On 5/02/17 the Director of Housekeeping and Maintenance Services/Designee firmly secured and repaired the sharp jagged edges of the handrails located below the activities calendar on Unit 3, firmly secured handrails between the two elevators, firmly secured handrails between the shower room and the janitor's closet, and firmly secured handrails outside of the soiled utility room. Additionally, the Director of Housekeeping and Maintenance Services/Designee firmly secured the following handrails on Unit 4: handrails between rooms 410 and the supplies room, between the nursing supervisor's office and the tub room, below the activity calendar and between the soiled utility room and the soiled laundry room.
On 05/04/2017 the Director of Housekeeping and Maintenance Services completed the inspection of all handrails including the wrap around sections of the handrails in the common resident units throughout the facility to ensure that the environment is free from accident hazards. All deficient areas were repaired immediately. Additionally the Director of Housekeeping and Maintenance Services instructed the RN Nurse Managers and Supervisors that should they see or are informed of any handrails including the wrap around sections of the handrails in the common resident units that are loose fitting or in disrepair that they should document it in the Maintenance Log located on each resident unit so the issue can be addressed in a timely manner.
The Director of Housekeeping and Maintenance Services/Designee will conduct quarterly inspections using an audit tool of all handrails including the wrap around sections of the handrails in the common resident units throughout the facility to ensure that the environment is free from accident hazards.
The Director of Housekeeping and Maintenance Services/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure no recurrence. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Housekeeping and Maintenance Services/Designee

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (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; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews during the recertification survey, the facility did not ensure that the resident's medication regimen was free from irregularities. Specifically, the unit nurses administered medications that were not in accordance with the physician's orders [REDACTED]. (Resident #90 and # 141). This was evident for two residents reviewed for Unnecessary Medications. (Resident #90 and #141). The findings are: 1) Resident # 90 is a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented clear speech, severe cognitive impairment and extensive assistance for activities of daily living. physician's orders [REDACTED]. A review of the facility's policy for Hours of Medication administration documents BID ( twice a day) to be administered at 9:00 am and 5:00 PM. A review of the facility's policy for Administration of Medications documents medication must be administered in accordance with physician's orders [REDACTED]. A review of the Administration Documentation History Detail Report documented the following medications were administered as follows: 1. Allopurinal 100 mg scheduled for 9:00 am and 5:00 PM was administered at 2:58 PM and at 5:00 PM on 4/30/17. 2. [MEDICATION NAME] Acid 500 mg scheduled for 9:00 am and 5:00 PM was administered at 2:58 PM and at 5:00 PM on 4/30/17. The medications were administered at two hour intervals between dosages instead of the eight hour interval between doses per the physician's orders [REDACTED]. Review of the Drug Recommendation insert for [MEDICATION NAME] acid documented: In order to benefit from from the medication, remember to use it at the same time each day to keep the amount of medication in your blood constant. Review of the Drug Recommendation insert for Allupurinol and [MEDICATION NAME] acid documented: Missed dose-if it is time for the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. On 5/02/17 at 1:00 PM and on 5/09/17 at 7:50 AM, the Licensed Practical Nurse (LPN) # 2 was interviewed and stated that she was the only nurse assigned to the unit on 4/30/17. The LPN stated that she had to administer over one hundred medications to forty residents. The LPN further stated that she usually completes morning medications in the afternoon at times by 3:00 PM, if there's an emergency. The LPN also stated that she worked late on 4/30/17 (until 6:00 PM) in order to complete the required tasks and documentation at the end of the shift. She stated that she was aware that she should have informed her supervisor that morning medications were running late and that the doctor should have been made aware. On 5/04/17 at 11:20 am the RN/NM (Registered Nurse/Nurse Manager) (# 3) was interviewed and stated that she was aware that staffing was an issue and that she had spoken about the need for an additional nurse on the unit for the entire shift, to assist with the morning medication administration. The RN further stated that she was aware that the unit LPN was administering medications late into the day and that she tried to provide assistance, at times performing wound care or covering the dining room during meals as well as making rounds. An interview was conducted with the unit attending physician on 5/03/17 at 1:45 PM. The physician stated that he expected that his orders be followed in regard to the intervals between doses and that the medications could be given one hour before or after the scheduled time. The resident is receiving [MEDICATION NAME] Acid due to his psychiatric [DIAGNOSES REDACTED]. The physician further stated that he would order a stat ( immediately) blood level for [MEDICATION NAME] Acid to ensure no harm was done. Review of Stat [MEDICATION NAME]/[MEDICATION NAME] acid blood level result dated 5/04/17 documented 28.9 (normal range-50.0-125.0). The previous [MEDICATION NAME]/[MEDICATION NAME] Acid blood levels dated 12/06/16 documented the following level-32.2 An interview was conducted with the Director of Nursing (DON) on 5/09/17 at 3:00 PM. The DON stated that there have been staffing concerns which had been addressed with corporate leadership. The DON further stated that she was not aware that the morning medications were being given out late in the day and that the unit the nurses were responsible for informing their supervisors and the doctors when medications were not administered as ordered. The DON continued that administering medications one hour before or after the scheduled or prescribed time was acceptable. 2) Resident #141 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data (MDS) Set 3.0 assessment dated [DATE] documented: adequate hearing, moderately impaired cognition and two person assistance for bed mobility and transfers. Observation were conducted from 5/05/2017 at 9:28 AM through 5/08/2017 at 12:41 PM of the resident who was observed lying in bed, in a hospital-type gown. During the observations the resident was alert, responsive to verbal stimuli and asking why she was in the facility, complaining about cramping in her feet and who brought her to the nursing home. physician's orders [REDACTED]. Cipro 500 mg(milligram) tablet-give 1 tablet (500 mg) by oral route immediately; then every 12 hours for 7 days. Automatic D/C (Discontinue) physician's orders [REDACTED]. 1. Monitoring-Accucheck (fingerstick glucose monitoring) BIW (twice per week). Schedule-every week on Sunday, Thursday at 5:00 PM 2. Calcium 600 + D (3) 600 mg (1,500) 200 unit tab (tablet)-give 1 tablet by oral route 2 times per day. Schedule every day at 9:00 am and 5:00 PM 3. [MEDICATION NAME] 10 gram/15 ml (milliliter) oral solution-give 30 milliliters by oral route q (every) Sunday, Tuesday and Friday at 9:00 am. Schedule every week on Sunday, Tuesday, Friday at 9:00 am. 4. Tylenol 325 mg tablet-give 3 tablets(975 mg) by oral route every 8 hours. Schedule every day at 6:00 am; 2:00 PM and 10:00 PM. The (Electronic Medical Record) Administration Documentation Audit Detail Report (which documented the administration times for medication administration) was reviewed and documented the following: Cipro 500 mg tablet was administered on 4/24/17 at 2:00 PM, instead of at 9:00 am per physician's orders [REDACTED]. [REDACTED]. 2. Calcium 600 + D (3) 600 mg (1,500)-200 unit tab was administered on 3/9/17 at 7:42 PM, 3/21/17 at 1:16 PM, 4/3/17 at 9:19 PM, 4/24/17 at 2:00 PM, instead of at 9:00 am and 5:00 PM, per the physician's orders [REDACTED]. [REDACTED]. The physician's orders [REDACTED]. The scheduled time that was documented for the nurses to administer the medication was 9:00 am and 5:00 PM which was not in accordance with the physician's orders [REDACTED]. There was no documented evidence to explain the reason for the medication administrations that were not in accordance with the physician's orders [REDACTED]. On 5/9/2017 at 8:57 AM, the Licensed Practical Nurse (LPN #3) (medication nurse) was interviewed and stated that if there are issues with the medication she would speak directly to the physician. When I am working by myself, I am responsible for administering medications to all 40 residents. Sometimes, a float (LPN) will be assigned to help administer the medications. Administration of the medications are documented in the electronic medical record. You are supposed to document upon administration of the medications but if you're by yourself you do not have time to document right away, so we document later. On 4/24/17, there was no second nurse on duty, so the medications were given late. I know the medications were supposed to be given as scheduled. I was taught to give the medication either one hour before or one hour after. I did not report to the RN Manager or the physician that I had administered the medications late. There are instructions on the blister pack but I do not have time to read it when I have to give out medications to 40 residents. On numerous occasions, I have reported to the supervisory staff that I need help since I cannot administer the medications for all 40 residents on a timely basis. I am the sole person responsible for administering the medications on this unit. On 5/9/2017 at 9:41 AM, The Registered Nurse Manager (RN #3) was interviewed and stated that the LPN's are aware that medications can be administered one hour before or one hour after the scheduled time. The protocol is when the medication is given late, the nurses are responsible for calling the physician to obtain an order to hold the next dose or administer the medication as scheduled. There have been staff cutbacks since last year, so I have been helping with treatments, sitting in the dayroom for lunch time, and toileting the residents as well. It is stressful as an LPN, who is under time constraints to administer the medications and then document in a timely manner. On 5/9/17 at 1 PM the attending Physician was interviewed and stated that he was not aware that medication were being administered beyond the scheduled time frames. 415.12 (l)(1)

Plan of Correction: ApprovedJuly 10, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will ensure that the resident's medication regimen is free from irregularities and that the administration of medications by licensed nurses are in accordance with the physician's orders [REDACTED].
Resident #90 was evaluated by the MD to determine if there were any adverse effects of the deficient practice i.e.
1. the administration of Allopurinal 100 mg at 2:58 PM and 5:00 PM.
2. the administration of [MEDICATION NAME] Avid 500 mg at 2:58 PM and 5:00 PM.
Resident #90 was also evaluated by the MD to determine if there were any adverse effects of the deficient practice. There were none noted.
LPN #2 was given a one-to-one re-education on the facility's Medication Administration Policy as well as a counseling for the deficient practice. A Medication Error form was completed which was reviewed by the MD, the DON, and Pharmacist.
Resident #141 was evaluated by the MD to determine if there were any adverse effects of the deficient practice i.e.
1.[MEDICATION NAME] mg tablet was administered on 4/24/17 at 2:00 PM, instead of at 9:00 am per physician's orders [REDACTED]. 2. The Accucheck was performed on 3/6/17 at 7:42 PM and on 3/12/17 at 7:55 PM, instead of at 5: 00 PM per the physician's orders [REDACTED].
3. Calcium 600 + D (3) 600 mg (1,500)-200 unit tab was administered on 3/9/17 at 7:42 PM, 3/21/17 at 1:16 PM, 4/3/17 at 9:19 PM, 4/24/17 at 2:00 PM, instead of at 9:00 am and 5:00 PM, per the physician's orders [REDACTED]. 4. [MEDICATION NAME] 10 gram/15 ml ora solution was administered on 3/21/17 at 1:16 PM, 4/2/17 at 10:45 am, 4/11/17 at 1:00 PM and 4/3017 at 1:57 PM, instead of at 9:00 am per the physician's orders [REDACTED]. No adverse effects were noted as a result of the deficient practices.
A random sample of 20 residents from each nursing unit was collected to ascertain if there were any deficient practice with respect to medications being administered as ordered and scheduled per the physician's orders [REDACTED].
Systemic Changes:
1. The DON will review the staffing levels for LPN's so that there are 2 LPN on each resident units (Unit 1, Unit 2, Unit 3, Unit 4, Unit 5, Unit 6) for all the 8 AM - 4 PM shifts as well as the 4 PM - 12 AM shifts.
2. The DNS/Designee will, after consultation with the MD and the Pharmacists, will review the medication times for medications given between 8 AM and 4 PM and create at staggered timing system to accommodate the timely administration of medication.
3. The Pharmacy Consultant will review the physicians orders including the scheduled times for medication administration and the medication administration records for each resident on a monthly basis to ensue that here are no irregularities. Any irregularities noted will be documented along with the corrective actions taken.
4. The DON/Designee will inform the MD of all irregularities in the administration of medications. When deemed necessary the MD and DON/Designee will review the Drug Recommendation insert in addressing irregularities. There will be clear documentation to explain follow up as to any abnormalities.
The ADON/Designee re-educated all nursing staff on the facility's Medication Administration Policy. RN Nurse Managers and Supervisors will conduct random daily audits of the medication administration using the Administration Documentation History Detail Report to ensure the timely administration and documentation of resident's medication.The DON/Designee will conduct monthly audits consisting of 20 randomly selected residents (4 per resident unit)using the Medication Administration Audit Tool to determine if licensed nursing staff are adhering to the facility's Medication Administration Policy. Additional re-education and training an/or counseling will be conducted as necessary.
The DON/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficiencies in infection control practices as well as those relating to the use of surgical mask relating to influenza and all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Nursing/Designee

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (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. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observations, record review, and interviews, the facility did not ensure that foods were stored and served under sanitary conditions or sanitation practices maintained to prevent food borne illness. Specifically, (1) Cold food items were not maintained and served at the proper temperatures during the lunch service; (2) Cooking pots and steam table serving pans were not sanitized appropriately and (3) Unlabeled and undated resident food items were stored in two resident refrigerator pantries. This was evident during the Kitchen/Food Service Observation task on 3 of 5 floors (Floors 2, 5, and 6). The findings are: 1) On 5/3/17 at 11:00 AM, an observation was conducted of Food Service Worker (FSW) (#1) on Floor 2, as the worker was setting up the steam table. There was a plastic container on the counter (with partially melted ice below the items) that contained: 3 sandwiches (tuna fish, cheese, and peanut butter and jelly), 1- 4 ounce (oz.) Yogurt and multiple bowls of applesauce. The sandwiches and yogurt were placed on top of the bowls of applesauce. On floor 2 on 5/3/17 at 11:45 AM, the FSW (#1) tested temperatures on floor 2 and the following observed: Tuna sandwich- 52 degrees Fahrenheit; Cheese sandwich- 61 degrees Fahrenheit; 4 oz. Yogurt- 46 degrees Fahrenheit. On floor 5 on 5/4/17 at 11:48 AM, the FSW (#1) took the sandwiches the sandwiches from the dining room refrigerator which were stored in a plastic container on ice and took the temperatures of the cold food items as follows: Tuna sandwich- 45 degrees Fahrenheit; Cheese sandwich- 45 degrees Fahrenheit. On 5/3/17 at 11:55 AM, FSW #1 was interviewed and stated that he starts setting up the cold food items at 11:00 AM by placing the items in the plastic bin with ice and placing the bin on the counter. Sandwiches are prepared in the kitchen around 10:00 AM, and they are brought up to the units around 11:00 AM. The sandwiches and other cold food items are kept in the unit dining room refrigerators until meal service. FSW #1 stated the sandwiches and yogurt temperatures should be below 40 degrees. There was no documented evidence of a policy and procedure for testing food temperatures on the unit floors. 2) On 5/3/17 from 12:00 PM to 12:15 PM, an observation of FSW (#2) performing the pot sanitation procedure was conducted. A three sink compartment sink was observed as follows: A wash sink, rinse sink and sanitizing solution sink. FSW (#2) scraped off mashed potatoes from the sides of a large stock pot in the sink, washed and scrubbed it using a green-blue scourer sponge and soap in the wash sink. The pot was then immersed in the sanitizing solution and pulled the pot out almost immediately and placed the pot on the drying shelf. The procedure was duplicated by FSW (#2) when washing and sanitizing a small stock pot and a steam table serving pan. On 5/3/17 at 12:15 PM, FSW#2 was interviewed and stated he has been doing the pot wash for many years and works five days a week. He stated the proper procedure is to wash and rinse the pots, then place them in the sanitizing solution for 15 seconds. He further stated he did not know why he didn't wash the pots properly. San-It sanitize (for pot washing) label documented-To sanitize pre-cleaned immobile food processing equipment and surface-flood the area with a 200 to 400 PPM (Parts Per Million) active quaternary solution for at least 60 seconds. The facility policy and procedure titled Dishwashing and Manual(NAME)washing (dated 5/3/17) documented-A three compartment sink is set up with for wash, rinse and sanitizing. Items being sanitized are completely immersed in the solution for at least 60 seconds or as recommended by the manufacturer for the chemical being used. Quaternary ammonium-200 ppm. Immerse completely for 60 seconds. On 5/9/17 at 10:12 AM, the Food Service Director (FSD) was interviewed and stated that sandwiches are prepared in the kitchen before 10:00 AM and placed in the refrigerator in the kitchen. The FSW assigned to each floor takes the sandwiches out of the refrigerator around 11:00 AM and brings it up to the unit floors. The FSW then places the sandwiches in the dining room refrigerator on ice. The FSW sets up the cold station on the dining room counter right before meal service. The cold station set up includes putting desserts, milk, and sandwiches in plastic containers filled with enough ice to cover the food items. Temperatures are taken after set up and 41 degrees is the highest temperature the cold foods should reach. The FSD stated the pot washer is expected to scrape food off the pots and pans, then scrub with soap in the wash sink, rinse in the middle sink, and immerse in the sanitizer sink for 60 seconds. The FSD stated the dietary department is not responsible for the refrigerator pantries on the units that holds resident food. 3) On 5/2/17 at 9:41 AM, the 6th floor unit pantry refrigerator was observed. There was one undated bag containing a hamburger and onion rings. On 5/2/17 at 9:42 AM and 5/9/17 at 10:31 AM, Registered Nurse (RN) Manager #1 was interviewed and stated all food should be dated and discarded within 48 hours. The nurse on the unit in the morning is responsible for checking the pantry refrigerator for temperature, cleanliness, and to make sure the food is properly labeled. On 5/9/17 10:51 AM, Licensed Practical Nurse (LPN) #1 was interviewed and stated she checks the refrigerator temperature during morning rounds. She further stated she also checks the food to make sure it is labeled and dated, and all food that is older than 24 hours or unlabeled is discarded. She stated that the LPN and RN are both responsible for discarding expired food. She stated all nursing staff are aware that resident food should be labeled with name and date before putting it in the refrigerator. She stated that it is possible the unlabeled food was overlooked. On 5/2/17 at 9:56 AM, the 5th floor pantry refrigerator was observed. There were 3 containers of prepared food with no labels. The Registered Nurse (RN) Manager discarded the food immediately. On 5/2/17 at 9:59 AM and 5/9/17 at 10:19 AM, Registered Nurse (RN) Manager #2 was interviewed and stated food must be labeled and dated by the family and then staff put it in the refrigerator. She further stated food is kept for 48 hours, but if it is a food like fish, she will discard it after 24 hours. All nursing staff should make sure food is labeled and dated prior to putting it in the refrigerator. The nurses check the refrigerator temperature daily and look at the dates on the food. She also stated a Certified Nursing Assistant (CNA) is assigned to check the pantry daily. The CNA is responsible for checking the pantry refrigerator for cleanliness and making sure old and undated food is discarded. She stated the CNA assigned to the pantry on 5/2/17 was a floating CNA and is not working today. On 5/9/17 at 10:24 AM, CNA #1, who was currently assigned to the pantry, was interviewed. She stated that she checks the pantry in the morning to make sure the pantry refrigerator is clean and tidy, and anything that is not supposed to be there is discarded. She checks the food to make sure everything is labeled and dated, and all unlabeled food is discarded. She stated food is discarded after 24 hours. The Policy and Procedure for Pantry dated 3/2015 documented: 1. Food items will be identified with name of owner and date placed in designated refrigerator. 2. Dietary and nursing staff will be responsible to ensure food items stored in pantry, refrigerators and freezers are not expired or past perish dates. 415.14(h)

Plan of Correction: ApprovedJune 5, 2017

The facility will ensure that foods are stored and served under sanitary conditions and sanitation practices maintained to prevent food borne illness. Further the facility will ensure the following: (1) that cold food items are maintained and served at the proper temperatures during the lunch service; (2) cooking pots and steam table serving pans are sanitized appropriately; and (3) resident food items stored in resident refrigerator in pantries are labeled with the resident's name and dated.
On 05/03/2017 the Food Service Director, upon being informed that the Tuna sandwich tested at 45 degrees Fahrenheit, the Cheese sandwich tested at 45 degrees Fahrenheit, and the Yogurt tested at 46 degrees Fahrenheit immediately discarded all these items.
The Food Service Director went to the other five resident dining areas and also removed and discarded all tuna sandwiches, cheese sandwiches, and yogurts. The Food Service Director informed the RN Nurse Managers and the nursing dining room staff that request for tuna sandwiches, cheese sandwiches, and yogurts are to be made to the kitchen when they are needed and at which time a member of the kitchen staff will deliver it to the dining room. Food Service Worker #1 was instructed on procedure for tuna sandwiches, cheese sandwiches, and yogurts.
The Food Service Director in-serviced for all Food Service employees, including Food Service Worker #1, and outline the procedure for ensuring that foods are stored and served under sanitary conditions and sanitation practices maintained to prevent food borne illness paying specific attention to the procedure for the requesting and delivery from the Food Service staff of tuna sandwiches, cheese sandwiches, and yogurts for residents. The Food Service Director also reviewed the facility's Policy and Procedure for Testing Food Temperatures on the resident unit floors.
On 05/03/2017 all pots previously washed by Food Service Worker #2 during his shift were re-washed following the facility's policy and procedure titled Dish washing and Manual(NAME)washing dated 5/3/17. The system used is a three compartment sink is set up with for wash, rinse and sanitizing -in that specific order- where items being sanitized are completely immersed in the solution for at least 60 seconds or as recommended by the manufacturer for the chemical being used.
The Food Service Director re-education all Food Service employees including Food Service Worker #2 outlining the procedure for ensuring that foods are stored and served under sanitary conditions and sanitation practices maintained to prevent food borne illness paying specific attention to the policy and procedure titled Dish washing and Manual(NAME)washing dated 5/3/17 and highlighting the three compartment sink is set up with for wash, rinse and sanitizing -in that specific order- where items being sanitized are completely immersed in the solution for at least 60 seconds or as recommended by the manufacturer for the chemical being used.
The Food Service Director/Designee will conduct weekly inspections of all resident dining rooms during meal times to ensure that foods are stored and served under sanitary conditions or sanitation practices maintained to prevent food borne illness and that cold food items are maintained and served at the proper temperatures during the meal service. Findings will be documented on an audit tool.
The Food Service Director/Designee will also conduct weekly inspections for one month them monthly of the cleaning/sanitizing process to ensure that of all resident dining rooms during meal times to ensure that cooking pots and steam table serving pans are cleaned and sanitized appropriately, in that, a three compartment sink is set up with for wash, rinse and sanitizing -in that specific order- and that items are completely immersed in the solution for at least 60 seconds or as recommended by the manufacturer for the chemical being used. Findings will be documented on an audit tool.
On 5/2/17 the Registered Nurse Manager for the immediately remover from the refrigerator and discarded the 3 containers of prepared food without labels. The Director of Nursing instructed the Registered Nurse Managers on resident units 2, 3, 4, and 6 to inspect their respective pantry refrigerators to ensure that all resident food items stored in resident refrigerator in pantries are labeled with the resident's name and dated. There were no other deficient practice found.
The ADON/Designee re-educated all nursing staff on the facility's Policy and Procedure for Pantry.
During daily rounds the Registered Nurse Manager/Designee will inspect their respective pantry refrigerators to ensure that all resident food items stored in resident refrigerator in pantries are labeled with the resident's name and dated. The Director of Nursing/Designee will conduct weekly inspection pantry refrigerators to ensure that all resident food items stored in resident refrigerator in pantries are labeled with the resident's name and dated. Findings will be documented on an audit tool.
The Food Service Director/Designee a well as the Director of Nursing/Designee will report quarterly to the Quality Assurance Committee all negative findings and deficient practice observed and how these issues were addressed. The Quality Assurance Committee will monitor the corrections to ensure that they are effective.
Responsible party: Food Service Director/Designee

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observations and interviews during the recertification survey, the facility did not ensure that the environment was free from accident hazards. Specifically: during the initial tour loose fitting handrails in the common areas of the resident units were observed. This was evident on two 2 of 5 resident units. (Units 3 and 4). The findings are: On Unit 3 on 05/02/17 at 10:05 am, the following was observed during the initial tour: The wrap around handrails located below the activities calendar was not firmly secured and observed with sharp jagged edges. Additionally, there were loose handrails between the two elevators, between the shower room and the janitor's closet and outside of the soiled utility room. On the 4th floor unit the following was observed: Loose handrails located between rooms 410 and the supplies room. Loose handrails located between the nursing supervisor office and the tub room. Loose handrails located below the activity calendar. Loose handrails located between the soiled utility room and the soiled laundry room. On 05/03/07 at 8:20 am, a portion of the wrap around handrail fell down as the SA (State Agency) demonstrated to the nurse manager how loose fitting the handrail was. The 3rd floor RNM (Registered Nurse Manager) was interviewed on 05/03/17 at 8:25 am and stated that the staff needed to be more vigilant about reporting needed repairs. The RN further stated that a maintenance log book is located on the unit. A review of the maintenance book revealed no documented evidence of the request for the handrail repairs. The Director of Housekeeping and Maintenance Services was interviewed on 05/04/17 at 11:00 am and stated that there is a maintenance log book on the units that is used to write down any repairs needed. This book is reviewed every day for any needed repairs. The Director further stated that the handrails are not often checked and that this will need to be implemented. 415.12(h)(1) .

Plan of Correction: ApprovedJune 5, 2017

The facility will ensure that the environment is free from accident hazards paying special attention to handrails in the common resident areas on units.
On 05/03/2017 the Director of Maintenance and Housekeeping inspected and repaired the following items on the 4th floor resident unit:
1. Loose handrails located between rooms 410 and the supplies room.
2. Loose handrails located between the nursing supervisor office and the tub room.
3. Loose handrails located below the activity calendar.
4. Loose handrails located between the soiled utility room and the soiled laundry room.
On 05/03/2017 the Director of Housekeeping and Maintenance Services inspected and repaired the wrap around handrail on the 3rd floor resident unit.
On 05/04/2017 the Director of Housekeeping and Maintenance Services completed the inspection of all handrails including the wrap around sections of the handrails in the common resident units throughout the facility to ensure that the environment is free from accident hazards. All deficient areas were repaired immediately. Additionally the Director of Housekeeping and Maintenance Services instructed the RN Nurse Managers and Supervisors that should they see or are informed of any handrails including the wrap around sections of the handrails in the common resident units that are loose fitting or in disrepair that they should document it in the Maintenance Log located on each resident unit so the issue can be addressed in a timely manner.
The Director of Housekeeping and Maintenance Services/Designee will conduct quarterly inspections and document the findings on an audit tool of all handrails including the wrap around sections of the handrails in the common resident units throughout the facility to ensure that the environment is free from accident hazards.
The Director of Housekeeping and Maintenance Services/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Housekeeping and Maintenance Services/Designee

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observations and interviews during the recertification survey, the facility did not ensure that housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior. This was evident on 2 of 5 resident units. (Unit 3, and Unit 4). The findings are: On 05/02/17 at 10:05 am during the initial tour, the following was observed on Unit 3: -Window curtains in rooms 302, 303, 314, 317, and 319 were dusty, torn and dirty. The window sills had an accumulation of dirt, soot, dust and debris. The windows were opaque and with streaks. The bedside tables were dusty and worn. The bedroom walls were stained and with black streaks -Room 317 had torn and stained privacy curtains -Room 309 A-the clothing closet had a loose, unsecured side panel -Two holes were observed in the plastered bathroom wall located across from room 307 -There were broken floor tiles in the dining room -The air conditioner located in the dining room area was layered with black dirt, and dust with the cover unhinged -The walls in the dining room were dirty with streaks and dried food particles. The radiator in the dining room was streaked with food stains -The dining room wooden tables were worn and disrepair -An unattended yellow bucket filled with water and an immersed mop was observed in the corridor -The clothing hampers in rooms 302, 303, 317 were observed with no lid covers. The hampers were stained with ground in dirt -The clean linen cart covers were stained, torn and covered with clear tape -The base to the blood pressure machine was observed with an accumulation of dirt, dust and debris -The bolster cushion for resident # 217 in room 309 B was torn exposing the inner foam. The back and arm rest of the wheelchair was torn -The back panel of the wheelchair for resident # 89 in room 314 B was torn in several places Unit 4: -A hole in the ceiling and brown ceiling tiles above the microwave were observed in the pantry -Brown ceiling tiles were observed in the shower/tub room located across from room 419. -The wooden tables in the dining room area were in disrepair -The dining room windows were streaked and dirty The porters from units 3 and 4 were interviewed on 05/04/17 at 11:00 am and 11: 05 am respectively. The porters stated that they have a cleaning schedule and are responsible for dusting, mopping, emptying the garbage and cleaning the dining room. The porters further stated that the supervisors are notified if repairs are needed logged in the maintenance log book on every unit. Any housekeeping supplies and or equipment is not to be left unattended for safety reasons. The Director of Housekeeping and Maintenance Services was interviewed on 5/04/17 at 11:00 am. The Director stated he has been employed at the facility for eight months and is responsible for the daily safety and functioning of the facility. He makes daily morning rounds on every floor beginning at 7:30 am, inspecting the hallways and rooms and focusing on the cleanliness of floors, bathrooms, and safety conditions. If he encounters incomplete or inadequate work, the particular staff is notified to re-do the work. Morning meetings with the staff are conducted to discuss issues that are reported or observed. One porter is assigned per floor and is responsible for sweeping, mopping, dusting and disposing of garbage. We do complete room cleaning for all 20 rooms on each floor as scheduled. The Director further stated that the window curtains were in need of repair and added that there were no replacement curtains. The privacy curtains were replaced after washing. There is a maintenance log book on the units that is used to write down any repairs needed. This book is reviewed every day for any repairs. 415.5(h)(2)

Plan of Correction: ApprovedJune 21, 2017

The facility will ensure that housekeeping and maintenance services are provided to maintain a sanitary, orderly and comfortable interior.
Between 05/04/2017 and 05/19/2017 the Director of Maintenance/Designee inspected rooms 302, 303, 314, 317, and 319 on Unit 3 and completed the following:
a) removed window curtains on Unit 3 from rooms 302 and 303 were replaced with new ones. Window curtains in rooms 314, 317, and 319 that were removed, laundered, and then replaced
b) performed detailed cleaning of the window sills in rooms 302, 303, 314, 317, and 319 to remove the accumulation of dirt, soot, dust and debris
c) bedside tables were worn were replaced with new ones and all others that were dusty underwent detailed cleaning
d) bedroom walls were scrubbed to remove stains and black streaks
e) room 317 privacy curtains were removed and replaced with new ones

f) room 309 A clothing closet was removed and replace with a new one

g) the two holes in the plastered bathroom wall located across from room 307 were filled with plaster and the area painted

h) the broken floor tiles in the dining room were removed and replaced
i) the air conditioner located in the dining room area was cleaned to removed the layered black dirt and dust
j) walls in the dining room were cleaned to remove streaks and dried food particles
k) the radiator in the dining room was cleaned to remove all food stains
l) the dining room wooden tables were repaired and restrained so that they were no longer in a state of disrepair
m) the unattended yellow bucket filled with water and an immersed mop in the corridor was immediately removed
n) clothing hampers in rooms 302, 303, 317 were removed and replaced with new ones observed with no lid covers
o) the linen cart covers were removed and replaced with new ones
p) the base to the blood pressure machines were scrubbed to remove all accumulation of dirt, dust and debris
q) the bolster cushion for resident # 217 in room 309 B was removed and replaced with a new one. The arm rest of the wheelchair that was torn was removed and replaced with a new one

r) the back panel of the wheelchair for resident # 89 in room 314 B that was torn in several places was removed and replaced with a new one
s) the damaged ceiling tiles above the microwave in the pantry of Unit 4 were remover and replaced with new ones
t) the damaged ceiling tiles in the shower/tub room on Unit 4 across from Room 419 were removed and replaced with new ones.
u) the dining room tables on Unit 4 were ll checked and the ones in need of repair were removed from the unit, repaired, and later replaced
v) the windows in the dining room on Unit 4 were all washed so as to removed all dirt and streaks.
The Director of Housekeeping and Maintenance Services/Designee inspected a random sample of 30 resident's rooms to determine the condition of the following: window curtains in resident's rooms, window sills, bedside tables, bedroom and dining room walls, privacy curtains, clothing closets, floor tiles in the dining rooms, air conditioner located in the dining room areas and resident's rooms, radiator in the dining rooms and resident rooms, dining room wooden tables, clothing hampers in resident rooms, clean linen cart covers, base to the blood pressure machines, bolster cushion for residents, and the back panels and arm rests of the wheelchairs. The Director of Housekeeping and Maintenance Services identified affected areas and set a date of 06/15/2017 to be in compliance so that the facility provides housekeeping and maintenance services to maintain a sanitary, orderly and comfortable interior. The Corporate Director of Maintenance Planning, Engineering and Improvements will be responsible for repairing/replacing all windows that were could not be cleaned to remove its opaqueness and/or streaks.
The Maintenance Director/Designee will maintain a cleaning and maintenance schedule for all resident rooms, resident dining rooms, and resident tub/shower rooms. The schedule will indicate the selected that are to have detailed cleaning. The schedule in on a rotating basis which will ensure that all these areas will have a detailed cleaning at a minimum of once per month. The Maintenance Director/Designee and Director of Nursing/Designee will conduct monthly environmental rounds, using the work sheet, for all resident units which will include inspection of window curtains in resident's rooms, window sills, bedside tables, bedroom and dining room walls, privacy curtains, clothing closets, floor tiles in the dining rooms, air conditioner located in the dining room areas and resident's rooms, radiator in the dining rooms and resident rooms, dining room wooden tables, clothing hampers in resident rooms, clean linen cart covers, base to the blood pressure machines, bolster cushion for residents, and the back panels and arm rests of the wheelchairs to ensure that housekeeping and maintenance services are being provided to maintain a sanitary, orderly and comfortable interior. The Maintenance Director/Designee and Director of Nursing/Designee will use audit tools to document findings. The Maintenance Director/Designee will re-educate all maintenance, housekeeping, and nursing staff the importance of housekeeping and maintenance services were provided to maintain a sanitary, orderly and comfortable interior.
The Director of Housekeeping and Maintenance Services/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with respect rooms being maintained to latch in their frames as designed as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Housekeeping and Maintenance Services/Designee

FF10 483.10(h)(1)(3)(i); 483.70(i)(2):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: 483.10 (h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. (h)(3)The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. §483.70 (i) Medical records. (2) The facility must keep confidential all information contained in the resident?s records, regardless of the form or storage method of the records, except when release is- (i) To the individual, or their resident representative where permitted by applicable law; (ii) Required by Law; (iii) For treatment, payment, or health care operations, as permitted by and in compliance with 45 CFR 164.506; (iv) For public health activities, reporting of abuse, neglect, or domestic violence, health oversight activities, judicial and administrative proceedings, law enforcement purposes, organ donation purposes, research purposes, or to coroners, medical examiners, funeral directors, and to avert a serious threat to health or safety as permitted by and in compliance with 45 CFR 164.512.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interviews, the facility did not ensure that a resident's personal privacy was maintained during the delivery of care. Specifically, the Licensed Practical Nurse (LPN #4) did not pull the resident's privacy curtain or close the door while providing wound care. This was evident for 1 of 3 residents observed for pressure ulcer care. (Resident #276). The finding is: Resident #276 is a [AGE] year old with [DIAGNOSES REDACTED]. The 5-day Minimum Data Set (MDS) 3.0 assessment dated [DATE] documented: moderately impaired cognition, extensive to total dependence for bed mobility, transfer, dressing, toileting, grooming, bathing and presence of one unstageable deep tissue injury. On 5/4/17 at 10:10 AM, the unit LPN (#4) was observed providing wound care to the resident's unstageable deep tissue injury to the right foot. During the observation, the privacy curtain separating the resident from the roommate (who was present in the room during the observation) was not drawn around the bed, leaving the resident's right foot exposed and visible during the provision of wound care. The facility policy and procedure titled Quality of Life/Dignity (dated (YEAR)) documented that staff shall promote, maintain and protect resident privacy, including bodily privacy during assistance with personal care and during treatment procedures. A review of the inservice training provided to LPN (#4) documented: Residents' Rights- Lesson Plan completed on 11/30/16. Objectives of lesson included, .#3 .to evaluate and define dignity and respect and relate these definitions to patients and residents in medical settings . On 5/4/17 at 10:26 AM, LPN (#4) was interviewed and stated that she received training from the Assistant Director of Nursing (ADON) on drawing both privacy curtains and closing the doors before starting resident care. On 5/5/17 at 9:24 AM, the Registered Nurse Manager (RNM (#2) was interviewed and stated she routinely makes rounds of the floor to monitor the staff providing resident care. RNM (#2) further stated that staff are instructed to pull resident's privacy curtains and close the doors during resident care. She further stated she does not provide formal in-services but reminds staff informally. On 5/9/17 at 11:48 AM, the RN/ADON (Assistant Director of Nursing) was interviewed and stated the last in-service regarding resident dignity and rights was completed 11/30/16. The ADON further stated that the lesson plan objective includes preserving resident rights and privacy when staff are providing treatment by closing the door and pulling the curtains. 413.3(d)(1)

Plan of Correction: ApprovedJune 5, 2017

The facility will ensure that all residents personal privacy is maintained during the delivery of care.
Resident #276 was assessed by RN and evaluated by Social Worker to ascertain if there were and ill effects due to the breach in maintaining the resident's personal privacy during the delivery of care. No ill effects were noted. A random sample of 25 residents from each of the five (5) units was obtained and observations were made by a RN while treatments and/or personal care was being provided by Licensed Practical Nurses (LPN) and/or Certified Nursing Assistants (CNA) to ensure that resident's Quality of Life/Dignity were being maintained. No breaches in the facility's policy and procedures Resident Dignity/Privacy were observed. LPN #4 was given a one-to-one re-education on the facility's policy on Quality of Life/Dignity with special attention being paid to closing the room door and pulling the privacy curtains in multi-resident rooms during treatments and providing care.
All nursing staff will be re-educated on the facility's policy on Quality of Life-Dignity paying special attention to maintain the personal privacy of a resident during the delivery by closing the room door and pulling the privacy curtains in multi-resident rooms during treatments. The ADON/Designee will conduct random observation of 10% of the resident population, weekly for one month then monthly thereafter, of residents during personal care by CNAs and LPNs to ascertain if all resident's personal privacy/dignity is being maintained. Findings will be documented on the Resident's Dignity and Privacy Audit Tool. The ADON/Designee will pay close attention to the use of privacy curtains between residents in multi-resident rooms and making sure that there is minimal exposure of resident's naked body. Random observations will be conducted during all three (3) shifts. The ADON/Designee will document any negative findings and conduct on the spot re-education of staff. All negative findings will be reported to the DON/Designee and any follow up needed will be taken.
The DON/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and deficient practice observed with respect to adherence to the facility's policy on resident's Quality of Life/Dignity as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Nursing/Designee

FF10 483.10(g)(8)(i)(9)(i)-(iii)(h)(2):RIGHT TO PRIVACY - SEND/RECEIVE UNOPENED MAIL

REGULATION: (g)(8) The resident has the right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident through a means other than a postal service, including the right to: (i) Privacy of such communications consistent with this section; and (g)(9) communications such as email and video communications and for internet research. (i) If the access is available to the facility (ii) At the resident's expense, if any additional expense is incurred by the facility to provide such access to the resident. (iii) Such use must comply with State and Federal law. (h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on record review and interview during the recertification survey, the facility did not ensure that mail was delivered within 24 hours. This was evident during the Resident Council President Interview related to mail delivery. The finding is: On 5/2/17 at 12:32 PM, the Resident Council President was interviewed and stated he was not sure about the mail delivery schedule, but he thought it was daily. The Resident Council Minutes dated 2/27/17, 3/27/17, and 4/27/17 were reviewed, and there was no review of the mail procedure documented. On 5/3/17 at 3:31 PM, the Finance Office Member in charge of resident mail was interviewed and stated, she sorts the mail Monday through Friday and leaves it in the mailbox for Recreation to distribute. She further stated that no one covers for her on the weekends, and the weekend mail is sorted and distributed on Monday. The Resident Council Suggested Agenda dated 1/12/17 documented Information to be reviewed at monthly meetings and mentioned in the minutes .Review mail procedures. The Facility policy for Resident Mail dated 9/16 documented: Resident mail needs to be delivered daily, including Saturdays. 415.3(d)(2)(i)

Plan of Correction: ApprovedJune 21, 2017

The facility will ensure that resident's mail will be delivered within 24 hours. Further the facility will also ensure that resident's right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident are not violated.
A search was conducted by the Director of Finance on 05/05/2017 at the mail delivery point to ensure that there were no existing resident's mail that was unsorted. None was found. The Director of Recreation met with the Resident's Council, including the president, and informed the Council that there will be mail delivery Monday thru Saturday.
The Director of Recreation/Designee will ensure that all resident's mail sorted by the Director of Finance/Designee will be delivered within 24 hours. Mail will be delivered Monday through Saturday. The Director of Recreation will notify all residents and/or their representatives of the Mail Delivery Policy. The Director of Recreation re-educated the Recreation staff on the Mail Delivery Policy. The Director of Recreation/Designee will monitor the mail delivery system weekly for 8 weeks then quarterly using the Mail Delivery Audit Tool to ensure resident's mail are being delivered within 24 hours of receipt Monday through Saturday and that resident's right to send and receive mail, and to receive letters, packages and other materials delivered to the facility for the resident are not violated.
The Director of Recreation/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and deficient practice observed with respect to adherence to the facility's policy on Resident's Mail well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Recreation/Designee

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility did not ensure that services provided were in accordance with the resident's written plan of care. Specifically, medications were not administered as ordered and scheduled per the physician's orders [REDACTED]. (Resident #90 and Resident #141). The findings are: 1) Resident # 90 is a [AGE] year old admitted on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set ((MDS) dated [DATE] documented clear speech, severe cognitive impairment and extensive assistance for activities of daily living. physician's orders [REDACTED]. A review of the facility's policy for Hours of Medication administration documents BID ( twice a day) to be administered at 9:00 am and 5:00 PM. A review of the facility's policy for Administration of Medications documents medication must be administered in accordance with physician's orders [REDACTED]. A review of the Administration Documentation History Detail Report documented the following medications were administered as follows: 1. Allopurinal 100 mg scheduled for 9:00 am and 5:00 PM was administered at 2:58 PM and at 5:00 PM on 4/30/17. 2. [MEDICATION NAME] Acid 500 mg scheduled for 9:00 am and 5:00 PM was administered at 2:58 PM and at 5:00 PM on 4/30/17. The medications were administered at two hour intervals between dosages instead of the eight hour interval between doses per the physician's orders [REDACTED]. Review of the Drug Recommendation insert for [MEDICATION NAME] acid documented: In order to benefit from from the medication, remember to use it at the same time each day to keep the amount of medication in your blood constant. Review of the Drug Recommendation insert for Allupurinol and [MEDICATION NAME] acid documented: Missed dose-if it is time for the next dose, skip the missed dose and resume your usual dosing schedule. Do not double the dose to catch up. On 5/02/17 at 1:00 PM and on 5/09/17 at 7:50 AM, the Licensed Practical Nurse (LPN) # 2 was interviewed and stated that she was the only nurse assigned to the unit on 4/30/17. The LPN stated that she had to administer over one hundred medications to forty residents. The LPN further stated that she usually completes morning medications in the afternoon at times by 3:00 PM, if there's an emergency. The LPN also stated that she worked late on 4/30/17 (until 6:00 PM) in order to complete the required tasks and documentation at the end of the shift. She stated that she was aware that she should have informed her supervisor that morning medications were running late and that the doctor should have been made aware. On 5/04/17 at 11:20 am the RN/NM (Registered Nurse/Nurse Manager) (# 3) was interviewed and stated that she was aware that staffing was an issue and that she had spoken about the need for an additional nurse on the unit for the entire shift, to assist with the morning medication administration. The RN further stated that she was aware that the unit LPN was administering medications late into the day and that she tried to provide assistance, at times performing wound care or covering the dining room during meals as well as making rounds. An interview was conducted with the unit attending physician on 5/03/17 at 1:45 PM. The physician stated that he expected that his orders be followed in regard to the intervals between doses and that the medications could be given one hour before or after the scheduled time. The resident is receiving [MEDICATION NAME] Acid due to his psychiatric [DIAGNOSES REDACTED]. The physician further stated that he would order a stat ( immediately) blood level for [MEDICATION NAME] Acid to ensure no harm was done. Review of Stat [MEDICATION NAME]/[MEDICATION NAME] acid blood level result dated 5/04/17 documented 28.9 (normal range-50.0-125.0). The previous [MEDICATION NAME]/[MEDICATION NAME] Acid blood levels dated 12/06/16 documented the following level-32.2 An interview was conducted with the Director of Nursing (DON) on 5/09/17 at 3:00 PM. The DON stated that there have been staffing concerns which had been addressed with corporate leadership. The DON further stated that she was not aware that the morning medications were being given out late in the day and that the unit the nurses were responsible for informing their supervisors and the doctors when medications were not administered as ordered. The DON continued that administering medications one hour before or after the scheduled or prescribed time was acceptable. 2) Resident #141 is a [AGE] year old admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Quarterly Minimum Data (MDS) Set 3.0 assessment dated [DATE] documented: adequate hearing, moderately impaired cognition and two person assistance for bed mobility and transfers. Observation were conducted from 5/05/2017 at 9:28 AM through 5/08/2017 at 12:41 PM of the resident who was observed lying in bed, in a hospital-type gown. During the observations the resident was alert, responsive to verbal stimuli and asking why she was in the facility, complaining about cramping in her feet and who brought her to the nursing home. physician's orders [REDACTED]. Cipro 500 mg(milligram) tablet-give 1 tablet (500 mg) by oral route immediately; then every 12 hours for 7 days. Automatic D/C (Discontinue) physician's orders [REDACTED]. 1. Monitoring-Accucheck (fingerstick glucose monitoring) BIW (twice per week). Schedule-every week on Sunday, Thursday at 5:00 PM 2. Calcium 600 + D (3) 600 mg (1,500) 200 unit tab (tablet)-give 1 tablet by oral route 2 times per day. Schedule every day at 9:00 am and 5:00 PM 3. [MEDICATION NAME] 10 gram/15 ml (milliliter) oral solution-give 30 milliliters by oral route q (every) Sunday, Tuesday and Friday at 9:00 am. Schedule every week on Sunday, Tuesday, Friday at 9:00 am. 4. Tylenol 325 mg tablet-give 3 tablets(975 mg) by oral route every 8 hours. Schedule every day at 6:00 am; 2:00 PM and 10:00 PM. The (Electronic Medical Record) Administration Documentation Audit Detail Report (which documented the administration times for medication administration) was reviewed and documented the following: Cipro 500 mg tablet was administered on 4/24/17 at 2:00 PM, instead of at 9:00 am per physician's orders [REDACTED]. [REDACTED]. 2. Calcium 600 + D (3) 600 mg (1,500)-200 unit tab was administered on 3/9/17 at 7:42 PM, 3/21/17 at 1:16 PM, 4/3/17 at 9:19 PM, 4/24/17 at 2:00 PM, instead of at 9:00 am and 5:00 PM, per the physician's orders [REDACTED]. [REDACTED]. The physician's orders [REDACTED]. The scheduled time that was documented for the nurses to administer the medication was 9:00 am and 5:00 PM which was not in accordance with the physician's orders [REDACTED]. There was no documented evidence to explain the reason for the medication administrations that were not in accordance with the physician's orders [REDACTED]. On 5/9/2017 at 8:57 AM, the Licensed Practical Nurse (LPN #3) (medication nurse) was interviewed and stated that if there are issues with the medication she would speak directly to the physician. When I am working by myself, I am responsible for administering medications to all 40 residents. Sometimes, a float (LPN) will be assigned to help administer the medications. Administration of the medications are documented in the electronic medical record. You are supposed to document upon administration of the medications but if you're by yourself you do not have time to document right away, so we document later. On 4/24/17, there was no second nurse on duty, so the medications were given late. I know the medications were supposed to be given as scheduled. I was taught to give the medication either one hour before or one hour after. I did not report to the RN Manager or the physician that I had administered the medications late. There are instructions on the blister pack but I do not have time to read it when I have to give out medications to 40 residents. On numerous occasions, I have reported to the supervisory staff that I need help since I cannot administer the medications for all 40 residents on a timely basis. I am the sole person responsible for administering the medications on this unit. On 5/9/2017 at 9:41 AM, The Registered Nurse Manager (RN #3) was interviewed and stated that the LPN's are aware that medications can be administered one hour before or one hour after the scheduled time. The protocol is when the medication is given late, the nurses are responsible for calling the physician to obtain an order to hold the next dose or administer the medication as scheduled. There have been staff cutbacks since last year, so I have been helping with treatments, sitting in the dayroom for lunch time, and toileting the residents as well. It is stressful as an LPN, who is under time constraints to administer the medications and then document in a timely manner. On 5/9/17 at 1 PM the attending Physician was interviewed and stated that he was not aware that medication were being administered beyond the scheduled time frames. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJune 21, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will ensure that services provided were in accordance with the resident's written plan of care and that medications are administered as ordered and scheduled per the physician's orders [REDACTED].
Resident #90 was evaluated by the MD on 05/02/2017 to determine if there were any adverse effects of the deficient practice i.e.
1. the administration of Allopurinal 100 mg at 2:58 PM and 5:00 PM.
2. the administration of [MEDICATION NAME] Avid 500 mg at 2:58 PM and 5:00 PM.
Resident #90 was also evaluated by the MD to determine if there were any adverse effects of the deficient practice. There were none noted.
LPN #2 was given a one-to-one re-education on the facility's Medication Administration Policy as well as a counseling for the deficient practice. A Medication Error form was completed which was reviewed by the MD, the DON, and Pharmacist.
Resident #141 was evaluated by the MD on 05/02/2017 to determine if there were any adverse effects of the deficient practice i.e.
1.[MEDICATION NAME] mg tablet was administered on 4/24/17 at 2:00 PM, instead of at 9:00 am per physician's orders [REDACTED].
2. The Accucheck was performed on 3/6/17 at 7:42 PM and on 3/12/17 at 7:55 PM, instead of at 5: 00 PM per the physician's orders [REDACTED].
3. Calcium 600 + D (3) 600 mg (1,500)-200 unit tab was administered on 3/9/17 at 7:42 PM, 3/21/17 at 1:16 PM, 4/3/17 at 9:19 PM, 4/24/17 at 2:00 PM, instead of at 9:00 am and 5:00 PM, per the physician's orders [REDACTED].
4. [MEDICATION NAME] 10 gram/15 ml ora solution was administered on 3/21/17 at 1:16 PM, 4/2/17 at 10:45 am, 4/11/17 at 1:00 PM and 4/3017 at 1:57 PM, instead of at 9:00 am per the physician's orders [REDACTED].
No adverse effects were noted as a result of the deficient practices.
A random sample of 10 residents from each nursing unit was collected to ascertain if there were any deficient practice with respect to medications being administered as ordered and scheduled per the physician's orders [REDACTED].
Systemic Changes:
1. The DON will review the staffing levels for LPN's so that there are 2 LPN on each resident units (Unit 1, Unit 2, Unit 3, Unit 4, Unit 5, Unit 6) for all the 8 AM - 4 PM shifts as well as the 4 PM - 12 AM shifts.
2. The DNS/Designee will, after consultation with the MD and the Pharmacists, will review the medication times for medications given between 8 AM and 4 PM and create at staggered timing system to accommodate the timely administration of medication.
The ADON/Designee re-educated all nursing staff on the facility's Medication Administration Policy. RN Nurse Managers and Supervisors will conduct random daily audits of the medication administration using the Administration Documentation History Detail Report to ensure the timely administration and documentation of resident's medication. The DON/Designee will conduct monthly audits consisting of 20 randomly selected residents (4 per resident unit)using the Medication Administration Audit Tool to determine if licensed nursing staff are adhering to the facility's Medication Administration Policy.
The DON/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Director of Nursing/Designee

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation, documentation review and staff interview during the recertification survey, the facility did not demonstrate a preventive maintenance program for resident room televisions on 5 of 6 floors. The findings include: During the life safety code survey conducted on 05/02/17 and on 05/03/17 between 9:00am to 2:00pm, it could not be determined that the flat screen televisions in resident rooms were inspected for safety. The facility did not provide documentation of the last inspection of the flat screen televisions. Although there were tags on some of the televisions, the information on the tags was not legible, and the facility personnel had no records of the purpose of the tags. In an interview on 05/02/17 at approximately 10:00am, the Director of Maintenance and Housekeeping stated that he has no documented inspections for the televisions in resident rooms. He further stated that he would conduct an inspection of all the televisions and start to keep a record. 2012NFPA101 2012NFPA 99 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 28, 2017

The facility will ensure that there is a preventive maintenance program for flat screen televisions in resident rooms, that these devices are inspected for safety, and that there is documentation of inspections. Additionally, all flat screen televisions in resident rooms will be tagged with date of last safety inspection.
On 05/04/2017 the Director of Maintenance and Housekeeping conducted an inspection of all flat screen televisions in resident rooms for safety. All flat screen televisions in resident rooms meat the manufacturer and safety standards. All flat screen televisions inspected were tagged with the date of inspection. The inspection date was also documented in the maintenance log kept in the office of the Director of Maintenance and Housekeeping.
The Maintenance Director/Designee will conduct quarterly inspections of all flat screen televisions in resident rooms meet the manufacturer and safety standards. The Maintenance Director/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure that the deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Maintenance Director/Designee

K307 NFPA 101:FIRE ALARM SYSTEM - TESTING AND MAINTENANCE

REGULATION: Fire Alarm System - Testing and Maintenance A fire alarm system is tested and maintained in accordance with an approved program complying with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Records of system acceptance, maintenance and testing are readily available. 9.6.1.3, 9.6.1.5, NFPA 70, NFPA 72

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

K-345 S/S=E Based on observation and staff interview, during the recertification survey, the facility did not maintained the building's fire alarm system in proper working order in accordance with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. Reference is made to the trouble conditions on the fire alarm panels, and the non-functional as designed fire alarm panels. This was noted on 6 of 6 resident floors and in the basement. The findings are: During the life safety code survey conducted on 05/02/17 and on 05/03/17 between 9:00am to 2:00pm, it was noted that the fire alarm display panels inspected did not function as designed and displayed trouble conditions. Examples included the following: - The 6th, 5th, 4th, and 3rd floor fire alarm panels that are located at the nursing stations, did not function as designed. The panels did not display the fire alarm system trouble conditions that existed on the other panels in the building. - The fire alarms panels located on the 2nd and 1st floors, and the basement displayed a pre-alarm, supervisory, and system trouble. In an interview on 05/02/17 at approximately 1:00pm, the Director of Maintenance and Housekeeping stated that the fire alarm system was previously upgraded and that he would contact the fire alarm maintenance company to address the issues with the system. 2012NFPA101 2010 NFPA 72 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 28, 2017

The facility will maintain the building's fire alarm system on all 6 of 6 resident floors and in the basement in proper working order in accordance with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. The facility will pay special attention to the trouble conditions on the fire alarm panels and the non-functional as designed fire alarm panels.
The Administrator/Designee contracted the services of Tikva Security to ensure that the building's fire alarm system and the fire alarm display panels functions as designed and that the fire alarm system displayed trouble conditions as they occur throughout the building.
On 05/04/2017 the Maintenance Director/Designee conducted an inspection and a test of the facility's fire alarm system and also inspected fire alarm display panels to ensure that there were no other negative findings or deficient practice. No others were noted.
The Maintenance Director/Designee will conduct quarterly inspections of the building's fire alarm system to ensure that the system is in proper working order in accordance with the requirements of NFPA 70, National Electric Code, and NFPA 72, National Fire Alarm and Signaling Code. The facility will continue to use the services of WNW & Son Fire Suppression to conduct monthly fire safety drills during which time the display panels will be inspected to ensure that it function as designed and displayed trouble conditions.
The Maintenance Director/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Maintenance Director/Designee

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

REGULATION: Spinkler System - Installation 2012 EXISTING Nursing homes, and hospitals where required by construction type, are protected throughout by an approved automatic sprinkler system in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. In Type I and II construction, alternative protection measures are permitted to be substituted for sprinkler protection in specific areas where state or local regulations prohibit sprinklers. In hospitals, sprinklers are not required in clothes closets of patient sleeping rooms where the area of the closet does not exceed 6 square feet and sprinkler coverage covers the closet footprint as required by NFPA 13, Standard for Installation of Sprinkler Systems. 19.3.5.1, 19.3.5.2, 19.3.5.3, 19.3.5.4, 19.3.5.5, 19.4.2, 19.3.5.10, 9.7, 9.7.1.1(1)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation, record review, and staff interview, during the recertification survey, it was determined that the facility was not provided with a complete automatic sprinkler system in that areas within the nursing home building was not provided with sprinkler coverage. Additionally, the fire resistive rating for the door to the main electrical room could not be verified for a room that was not provided with sprinkler coverage. This is a repeat deficiency. The findings are: During the life safety code survey conducted on 05/02/17 and on 05/03/17 between 9:00am to 2:00pm, the following was noted: 1. The nursing home building was not protected by a complete automatic sprinkler system. Areas that were not provided with sprinkler protection included: - the elevator motor room located on the roof. - the fish tank room located on the lobby level. - the vestibule in front of the conference room on the lobby level. - an air handler room located near the reception area on the lobby level. In an interview on 05/03/17 at approximately 10:35am, the Director of Maintenance and Housekeeping stated that he would contact the sprinkler maintenance company to install the sprinklers in the identified areas. A review of NYSDOH records for the 02/29/2016 recertification survey indicated that the areas were cited for not having sprinkler coverage. The facility's plan of correction indicated that the facility will ensure that all areas in the building are protected by an automatic sprinkler system in accordance with section 9.7. It further indicated that the Maintenance Director/Designee contracted the services of an outside Fire Suppression, Plumbing & Heating Corp. to fully sprinkle the facility in accordance with NFPA13. The areas that sprinklers coverage was added included but are not limited to: A section of the receptionist area on the lobby floor, The tank room off the conference room on the lobby floor, The vestibule/passageway adjacent to the conference room on the lobby, and the Machine rooms for the passenger and service elevators. 2. The required minimum of 90 minutes fire resistive rating for the door to the main electrical room that is located in the basement could not be verified. The main electrical room is not provided with sprinkler protection within and the fire resistance rating strip for the door was not legible. In an interview on 05/03/17 at approximately 10:00am, the Director of Maintenance and Housekeeping stated that he would try to clean the rating label on the door or have the door replaced. 2012NFPA101 2010 NFPA 13 NYCRR 711.2(a) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 28, 2017

The facility will provide a complete automatic sprinkler system in that areas within the nursing home building in accordance with NFPA 13, Standard for the Installation of Sprinkler Systems. Additionally, the facility will ensure that the fire resistive rating for the door to the main electrical room meets the fire safety code and that there is verifiable documentation records of system acceptance, maintenance and testing are readily available.
The Administrator/Designee contracted the services of WNW & Sons Fire Suppression, Plumbing & Heating Corp. to fully install sprinkles in the facility in accordance with NFPA13. On 05/04/2017 WNW & Sons Fire Suppression, Plumbing & Heating Corp. installed sprinklers in the following areas:
1. the fish tank room located on the lobby level.
2. the vestibule in front of the conference room on the lobby level.
3. the air handler room located near the reception area on the lobby level.
On 05/26/2017 WNW & Sons Fire Suppression, Plumbing & Heating Corp. submitted at contract to the Administrator for work to b done in the main electrical room door located in the basement. The work to be done will ensure that the facility meets the requirements that the main electrical room is provided with sprinkler protection. The contract made with WNW & Sons Fire Suppression, Plumbing & Heating Corp. states that .the work recommendation of adding two sprinkler heads in the elevator machine room on the roof at the above premises will be started by 5/31/17 and completed by 6/5/17. WNW & Sons Fire Suppression, Plumbing & Heating Corp. will also install a door with the required minimum of 90 minutes fire resistive rating for the door to the main electrical room that is located in the basement. The Director of Maintenance/Designee will also ensure there is documented evidence on hand to verify that the door meets the recommended standard.
The Maintenance Director/Designee conducted inspection of the facility's entire sprinklers and sprinkler piping to ensure that there were no other negative findings or deficient practice. No others were noted.
The Maintenance Director/Designee will conduct quarterly inspections of the facility to ensure that the sprinklers and sprinkler piping was maintained in accordance with NFPA13. The Maintenance Director/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Maintenance Director/Designee

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: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation, record review and staff interview, during the recertification survey, the facility did not properly maintain its sprinkler system in accordance with the requirements of 2011 NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Reference is made to a missing up to date flow test of the sprinkler system, and dusty and grease build up on sprinkler heads in the kitchen. The findings are: During the life safety code survey conducted on 05/02/17 and on 05/03/17 between 9:00am to 2:00pm, the following was noted: 1. The facility did not provide documentation for an up to date flow test of the building's automatic sprinkler system. During a record review on 05/03/17 at approximately 10:30am, it was noted that the last documented flow test of the sprinkler system was completed on 11/11/16 by an outside company. There was no documented flow test for the first quarter of (YEAR). In an interview at this time, the Director of Nursing stated that the missing sprinkler information would be provided by the conclusion of the survey. There was no up to date sprinkler testing information provided at the conclusion of the recertification survey. 2. During an inspection of the main kitchen (located on the 1st floor) on 05/03/17 at approximately 9:45am, it was noted that sprinkler heads were dusty and had grease build up in the vicinity of the range hood. In an interview at this time, the Director of Maintenance and Housekeeping stated that he would contact the sprinkler company to look into the concerns with the sprinkler heads. 2012 NFPA 101 2011 NFPA 25 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 28, 2017

The facility will properly maintain its sprinkler system in accordance with the requirements of 2011 NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Furthermore the facility will maintain an up to date record of the flow test of the sprinkler system, and will have scheduled maintenance of the sprinkler system to ensure that the system is free from dusty and grease build up on sprinkler heads in the kitchen and throughout the building.
On 5/04/2017 the Director of Maintenance conducted a flow test of the building's automatic sprinkler system. This test was documented of the building's Automatic Sprinkler System Flow Test Log. There were no negative findings as a result of the flow test of the building's automatic sprinkler system. The log was places in a binder and will be kept in the office of the Director of Maintenance.
The Maintenance Director/Designee will conduct quarterly flow test of the building's sprinkler system in accordance with the requirements of 2011 NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. The dates and times of the flow test and inspection will be documented on the building's Automatic Sprinkler System Flow Test Log which will be kept in the office of the Director of Maintenance.
The Maintenance Director/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Maintenance Director/Designee

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: May 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation, and staff interview, during the recertification survey, the facility did not ensure that smoke barriers were maintained to a ½ hour fire resistance rating. Reference is made to unsealed wire penetrations of the smoke barriers on 3 of 6 floors inspected. The findings are: During the life safety code survey conducted on 05/03/17 between 9:00am to 2:00pm, it was noted that the smoke barriers contained unfilled penetrations around wires (BX cables and data cables) on the 2nd, 3rd, and 4th floors. In an interview on the same day at approximately 12:15pm, the Director of Maintenance and Housekeeping stated that there were recent installations of a wireless internet system by an outside company. He further stated that he would check all the smoke barriers and seal all penetrations of the smoke barriers. 2012 NFPA 101 10NYCRR 711.2(a)(1) 10 NYCRR 415.29

Plan of Correction: ApprovedMay 28, 2017

The facility ensure that smoke barriers were maintained to a ½ hour fire resistance rating as evidenced by no unsealed wire penetrations of the smoke barriers on all floors.
On 05/04/2017 the Director of Maintenance and Housekeeping inspected and sealed all unfilled penetrations around wires(BX cables and data cables) on the 2nd, 3rd, and 4th floors with material of ½ hour fire resistance rating.
The Maintenance Director/Designee conducted inspection of the all other penetrations around wires (BX cables and data cables) to ensure that there were no other negative findings or deficient practice. No others were noted.
The Maintenance Director/Designee will conduct quarterly inspections of the facility to ensure that penetrations around wires (BX cables and data cables)are sealed with smoke barriers were maintained to a ½ hour fire resistance rating. The Maintenance Director/Designee will report to the Quality Assurance (QA) committee quarterly all negative findings and/or deficient practice with as well as all actions taken to ensure deficient practice does not recur. The QA committee will monitor the corrections to ensure that they are effective.
Responsible party: Maintenance Director/Designee