Northwoods Rehabilitation and Nursing Center at Moravia
August 28, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(e)(1)(2):COORDINATION OF PASARR AND ASSESSMENTS

REGULATION: §483.20(e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: §483.20(e)(1)Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident's assessment, care planning, and transitions of care. §483.20(e)(2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2018
Corrected date: October 26, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review during the recertification survey, the facility did not incorporate the recommendations from the pre-admission screening and resident review (PASRR) program level II determination (referral process for individuals who are known or suspected of having serious mental illness) into a resident's assessment, care planning, and transition of care. Specifically, Resident #4 was referred for a level II screening and the results were not obtained; Resident #29's level II recommendations were not implemented. Findings include: 1) Resident #4 was admitted to the facility on [DATE], re-admitted on [DATE], and had [DIAGNOSES REDACTED]. The 05/17/18 Minimum Data Set (MDS) admission assessment documented the resident had not had a level II PASRR screening/evaluation and did not have any conditions related to mental [MEDICAL CONDITION]/developmental disability (MR/DD). The resident had severe cognitive impairment, moderately severe mood symptoms, and exhibited verbal and physical behaviors. The resident's behaviors placed him at risk of physical injury, significant interference with care and participation in activities and social interactions. The resident did not receive any psychological therapy. The PASRR form dated 05/08/18 documented: - The resident had a [DIAGNOSES REDACTED]. - The MR/DD manifested itself prior to age 22 and was likely to continue, resulting in substantial functional limitations in three or more areas of major life activity; - The resident had not yet been deemed eligible to receive services and had not been referred by an agency that served persons with MR/DD; - The resident presented with evidence of cognitive/adaptive skill deficits that may indicate the presence of MR/DD; and - A referral was required for a level II evaluation by the Office of Mental [MEDICAL CONDITION] and Developmental Disabilities (OMRDD, now referred to as OPWDD). The Office for People with Developmental Disabilities (OPWDD) referral response letter dated 05/09/18 documented the resident's eligibility needed to be determined. A 05/09/18 social services progress note documented the social worker spoke to the social worker at the hospital and he was to receive a level II screen and patient review instrument (PRI, medical evaluation used to determine eligibility for skilled nursing care) from the hospital. Social services progress notes from 05/10/18 to 08/21/18 contained no documentation regarding a level II evaluation being obtained from the hospital. When interviewed on 08/30/18 at 10:00 AM, the social worker stated she oversaw admission. The purpose of the PASRR was to identify if the resident required additional services for MR/DD or mental illness (MI). A resident should not be admitted without a PASRR or level II screen. She was not aware the resident had a level II referral from his hospitalization in 05/2018 and was not aware the facility had not received the results of the evaluation or the recommendations. During an interview on 08/30/18 at 10:17 AM, the MDS Coordinator stated the facility did not currently have psychiatric services. She stated the facility should not have admitted a resident without the level II evaluation completed. 2) Resident #29 was admitted [DATE] and had [DIAGNOSES REDACTED]. The 05/09/18 Minimum Data Set (MDS) assessment documented the resident was not considered by the level II PASRR process to have serious mental illness and/or intellectual disability and there were no level II conditions present. The resident had intact cognition, minimal severity of mood symptoms, and worsening behaviors of care rejection. The resident did not receive psychological therapy or services during the assessment period. The 12/20/17 PASRR Level II recommendations included: - Psychiatric and medication evaluation by psychiatrist or physician, the resident would benefit from medical and mental health evaluations weekly; - Development of a written plan of psychiatric care would benefit resident to address depression, anxiety, and somatic symptoms related to reports of stomach issues; - Ongoing psychiatric consultation and medication management by a psychiatrist or licensed Prescriber weekly; - Recovery oriented clinical counseling focused on goal achievement monthly; and - Case management with daily monitoring and assessment of needed resource and services to assist with daily needs. The comprehensive care plan (CCP) initiated 05/03/18 documented the resident used [MEDICAL CONDITION] medications related to [DIAGNOSES REDACTED]. Interventions included administer medications as ordered, consult with pharmacy and physician to consider dosage reduction, review behaviors, interventions, and alternate therapies and their effectiveness, and educate family about risks and benefits of medications. The CCP did not address the resident's mental health symptoms, treatment, or behavioral interventions. Social service progress notes documented: - On 05/09/18, the social worker contacted the resident's former facility requesting the Patient Review Instrument (PRI, medical evaluation used to determine eligibility for skilled nursing care) and PASRR; - On 05/23/18, the social worker spoke with the resident's daughter, whose only concern was she wanted the resident to focus on mental health through counseling and the social worker informed her the resident will begin counseling on 05/25/18; - On 05/25/18, the resident was unable to participate in counseling due to sleeping, the resident declined when woken, and stated she would participate on 05/29/18; and - On 06/19/18, the resident declined her counseling appointment due to stomach pain and requested to be seen on 06/22/18, the social worker arranged an appointment. The physician's orders [REDACTED]. The psychologist's visit summaries documented: - On 06/12/18, the resident was seen for delusions regarding her physical health status and depressed mood, and the plan was to provide supportive psychotherapy; - On 06/15/18, the resident was very anxious and had delusions about her medical status, the plan was to continue treatment; and - On 06/22/18, the resident continued to address her delusions about her health, the plan was to continue treatment. There was no other documentation in the resident's record regarding psychological services and treatment. The social services progress notes did not contain any information regarding the status of the resident's psychological health care after 06/22/18. When interviewed on 08/30/18 at 10:00 AM, the social worker stated she oversaw admission. The purpose of the PASRR was to identify if the resident required additional services for MR/DD or mental illness (MI). She stated she was familiar with the resident's level II recommendations and the recommended services should have continued when she transferred to the facility. The social worker stated the resident was not receiving any of the recommended services at this time and she should be, as she had multiple mental health diagnoses. During an interview on 08/30/18 at 10:17 AM, the MDS Coordinator stated the facility did not currently have psychiatric services. She stated they formerly used a video-conferencing service for psychological services and that service ended. The resident frequently refused visits and the social worker should have written a progress note if the session did not occur. On 08/30/18 at 10:38 AM, the Administrator stated during an interview the resident had multiple diagnoses, the level II recommendations should continue and she was not receiving psychiatric evaluations weekly and she should be receiving them. 10NYCRR 415.11(c)

Plan of Correction: ApprovedSeptember 26, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

1)It was indicated on the PASARR for resident #4 that follow up was needed by OPWDD. They were contacted on 8/30/18 and again on 9/17/18 and state they can go no further with an evaluation for eligibility for services unless there is documentation that there was a disability prior to age 22. According to(NAME)Hamilton, social worker at Auburn Community Hospital, who completed the screen, she is not aware of any such documentation and may have initiated this process in error.
All Screens will be audited by 9/28/18 to insure that there are no other residents who have need for follow up that has been missed.
The Director of Social Work, Admissions has revised process of reviewing potential admissions to include the complete review of Screens (PASARR) for Level 2 results to insure that the facility can comply with recommendations prior to accepting for admissions.
An audit tool has been developed to document the outcomes of all screens on current residents and admissions going forward.
Audits will be completed monthly with results reported to the QAPI Committee. A compliance rate of 100% is necessary for appropriate follow up for admissions and readmissions.
The Social Work Director is responsible for this correction and will complete by 10/26/18 and ongoing.
2) Resident #29 was to receive mental health services according to the PASARR. She has been referred to CHE Services and has been seen on 9/7/18, 9/14/18 and 9/21/18; with a plan to continue weekly until the provider feels it is no longer necessary.
All screens will be audited by 9/28/18 to determine if there are any other residents with recommendation for follow up mental health services that have not been seen.
The Director of Social Work, Admissions has revised process of reviewing potential admissions to include the complete review of Screens (PASARR) for Level 2 results to insure that the facility can comply with recommendations prior to accepting admissions and readmissions.
An audit tool has been developed to document the results of the audits for current residents and will be used on an ongoing basis for admissions and readmissions.
Audits will be completed monthly with results reported to the QAPI Committee. A compliance of 100% is necessary to insure that residents receive appropriate follow up care.
The Social work Director will be responsible for completing these corrections by 10/26/18 and ongoing.

FF11 483.90(d)(2):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: §483.90(d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2018
Corrected date: October 26, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not maintain all mechanical/electrical equipment in safe operating condition. Specifically, the facility was not maintaining the washing extractors (washing machine) and dryer tumblers according to manufacturer's recommendations (did not document monthly/quarterly/bi-annual report inspections). Findings include: Review on 8/27/2018 of the washer extractor operation/maintenance book, indicated there were monthly and quarterly maintenance requirements. Monthly maintenance included: - check V-belts for determination of replacement or adjustment; - lubricate bearings and seals; - check overflow hose and drain hose for leaks; - clean inlet hose filter screens; - tighten motor mounting bolt locknuts and bearing bolt locknuts, if necessary; - clean lint from motor; - clean interior of machine, both basket and shell; and - ensure all electrical components free of moisture and dust. Quarterly maintenance included: - tighten door hinges and fasteners, if necessary; - tighten anchor bolts, if necessary; - verify that drain motor shield is in place and secure, if so equipped; - check all painted surfaces for bare metal; and - clean steam filter, where applicable. Review on 8/27/2018, of the dryer tumbler operation/maintenance book, indicated there were monthly, quarterly, and semi-annual maintenance requirements. Monthly maintenance included: - remove lint and debris from inside exhaust vent; - ensure even lint distribution over lint screen; - wipe any accumulated lint off the cabinet high limit thermostat and thermistor (heat sensor); and - clean lint and debris buildup from blower. Quarterly maintenance included: - clean air vents on drive motors; - clean lint from rear limit thermostat cover; - check and clean steam coils; - check flow of combustion and ventilation air; and - check belt tension and condition. Replace if necessary. Bi-Annual maintenance included: - check mounting hardware for any loose nuts, bots, or screws; - check gas connections for leakage; - check for loose electrical connections; - check steam connections for looseness and leakage; - remove all front panels and vacuum; - check cylinder and front panel seals; - inspect cabinet and inner panels for any damage, replace or repair as needed; and - clean burner tubes of any lint buildup. On 8/27/18 at 3:48 PM, the Environmental Services Director stated he was not aware that washers and dryers were required to be maintained as per manufacturer requirements, and there were no maintenance records. Some parts were being maintained monthly and quarterly but were not documented. On 8/27/18 at 4:00 PM, the Administrator stated she was not was aware it was required to follow manufacturer requirements for washers and dryers. 10 NYCRR 415.29 (k)

Plan of Correction: ApprovedSeptember 25, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
The Washer and Dryer Manuals have been reviewed. Monthly, quarterly and semi annual preventive maintenance measures will all be completed by 10/19/18.
The Preventive Maintenance schedule has been updated to include all of the items in the service manual for monthly, quarterly and annual maintenance. The tasks have been developed and will be carried out by the Environmental Service Director.
The tasks will be audited for the next 12 months with the results reported to the Safety and QAPI Committees. The initial results will be reported at the Committee meetings in (MONTH) on (MONTH) 22 and (MONTH) 24, respectively.
The Environmental Services Director is responsible for the completion of all corrections by 10/26/18.

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

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 30, 2018
Corrected date: October 26, 2018

Citation Details

Based on observation, interview, and record review during the recertification survey the facility did not maintain drugs and biologicals stored and labeled in accordance with currently accepted professional standards, and the expiration date when applicable for 1 of 1 medication storage rooms and 1 of 2 medication storage carts (medication cart #2) inspected. Specifically, inspection of medication storage room revealed 4 bottles of an expired medication and medication cart #2 had an opened, expired bottle of a stock medication in the bottom drawer. Findings include: On 08/27/18 at 12:50 PM, during a medication cart inspection with licensed practical nurse (LPN) #2 there was one bottle of Senna (laxative) 8.6 milligram (mg) opened and half full in the bottom drawer of medication cart #2. The pharmaceutical expiration date labeled was 6/2018. In the the supply room there were 4 bottles of Senna 8.6 mg with expiration dates of 6/18 in the locked overstock medication cabinet. When interviewed on 08/27/18 at 12:55 PM, LPN #2 stated the Senna 8.6 mg bottles were expired (6/18). Staff rarely used that type of medication as the physicians usually prescribed another type of laxative. She stated nurses were responsible for checking expiration dates when placing them in the medication carts, every couple of days, and prior to administering the medication. There was no designated person or shift responsible to check stock medication expiration dates. She stated the bottle had not been used as there was another bottle in the regular bin, this one was in the overstock bin. The LPN stated the DON was responsible for resupply of stock medications. When interviewed on 08/27/18 at 01:12 PM, the Director of Nursing (DON) stated LPNs were to take stock medication from the storage room as needed and were responsible for checking the expiration dates prior to administering each medication. The Administrator was responsible for resupplying the stock medications in the supply room. The night shift nurses were to check the carts weekly for expired medications, and to fill out an expired medication audit form when checking the carts and overstock room. When interviewed on 08/27/18 at 02:02 PM, the Administrator stated she ordered and restocked the overstock supply room cabinet and rotated stock front to back. She stated the night shift nurse was responsible to check the stock meds for expiration dates in the supply room and medication carts on a weekly basis, was not sure the exact day it was scheduled, and was not aware of any forms the nurse was to document that they completed the weekly task. 10NYCRR 415.18

Plan of Correction: ApprovedSeptember 26, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The Plan of Correction constitutes our written allegation of compliance for the deficiencies cited. However submission of this plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by State and Federal law.
Expired medication bottles were disposed of at time of finding, [DATE].
A review of all medication bottles in supply room and both medication carts were completed by end of day of findings, [DATE].
Medication carts, med room fridge, and clean utility room med cabinet will be checked for expired meds weekly by Nursing Staff, Sunday nights. Tasks will be signed for on a Night Shift Nurse Duties task Sheet.Policy was revised to indicate separate documentation for each specific location, shift responsible, and frequency. All staff was advised of this procedure change on [DATE].
The corrective actions will be monitored through quality measurement audits monthly by the Director of Nursing for 3 months and presented to QAPI Committee for review and determination if review period needs to be extended. Expected compliance rate >95%.
The Director of Nursing will be the person responsible for the correction of this deficiency by [DATE] and ongoing.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

Based on observation, record review and interview during the recertification survey, the facility did not ensure the testing of 1 of 1 generator (building generator) was maintained. Specifically; the facility's main and feeder circuit breakers were not inspected annually; the building generator 4 hour continuous exercise test was not completed in the last three years; and the monthly load test, at least 30% of generator capacity, for the building generator was not completed as required. Findings include: 1) Main and Feeder Circuit Breakers Not Inspected Annually During an interview on 8/28/2018 at 3:16 PM, the Environmental Services Director stated he was not aware that main and feeder circuit breakers were required to be inspected annually, and had no documented evidence it was completed. 2) Four Hour Continuous Exercise Test Not Completed During an interview on 8/28/2018 at 3:16 PM, the Environmental Services Director stated he was not aware that a four hour continuous exercise test was required every 3 years, and had no documented evidence it was completed. 3) Monthly Load Test Not Completed On 8/28/2018 at 3:52 PM, a surveyor in the generator room observed the total kilowatts on the generator nameplate was 62. Review on 8/28/2018 of weekly generator test reports for the building generator, revealed from 6/22/2017 to 5/30/2018 the monthly load tests were not equal to or greater than 30% of the generators capacity (62 kilowatt) . There were no load tests performed at greater than 30%. All of the load tests had the same load of 10.8 kilowatts, which was 18%. Also, ampere values were not documented for 3 of 8 identified load tests on the generator test reports. When interviewed on 8/28/18 at 4:00 PM, the Environmental Services Director stated he was not aware that 30% of the generators capacity had to be run during monthly load tests. 2012 NFPA 99: 6.4.4.1.1.3 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 10, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

1)The circuit breakers were inspected on 9/10/18.
Inspecting the circuit breakers has been added to the annual preventive maintenance plan with a form indicating each breaker to be inspected.
The results of the inspection will be presented to the Safety and QAPI Committees by 10/24/18.
The Environmental Services Director is responsible for completion by 10/24/18 and ongoing.
2)The 4 hour continuous test of the generator will be completed by Penn Power by 9/30/18.
The results of the 3 year test will be reported to the Safety and QAPI Committees by 10/24/18.
The Environmental Services Director is responsible for the completion by 10/24/18 and ongoing.
3) Penn Power will operate the generator under 30% capacity by 9/30/18. They will provide the documentation necessary so that the monthly load tests will be in compliance with regulation.
Capacity information will be tracked on the generator tracking sheets that are completed for both the weekly and monthly testing.
The results of the testing will be presented to the Safety and QAPI Committees by 10/24/18.
The Environmental Services Director is responsible for the completion by 10/24/18 and ongoing.

K307 NFPA 101:EMERGENCY LIGHTING

REGULATION: Emergency Lighting Emergency lighting of at least 1-1/2-hour duration is provided automatically in accordance with 7.9. 18.2.9.1, 19.2.9.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility's emergency light in the generator room was not tested and maintained as required. Specifically,the annual test for 90 minutes were not tested /documented. Findings include: Review on 8/28/2018 of the facility's fire drill report dated 12/22/2017 indicated the battery powered emergency light in the generator room was checked, but there was no time frame to indicate the length of this test. During an interview on 8/28/2018 at 11:13 AM, the Environmental Services Director stated the emergency light in the generator room was run for 2 hours in 12/2017 during a fire drill but was not documented. 2012 NFPA 101: 19.2.9.1, 7.9 2010 NFPA 110: 7.3.1 10NYCRR 415.29(a)(1&2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 10, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.

The battery operated emergency lighting was tested for over 90 minutes on 9/4/18; no issues with performance.
There is only one (1) battery operated light in the facility.
The testing documentation has been added to the other items for the generator with specific documentation of start and stop times of the test. Although the test was completed on 9/4/18, it will be repeated in (MONTH) for consistency.
Testing will be an agenda item for both the Safety Committee and QAPI Committee for the (MONTH) and (MONTH) meetings.
Environmental Services Director is responsible, correction is completed and will be ongoing.

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: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

Based on record review and interview conducted during the Life Safety Code survey, the facility's fire alarm system was not tested in accordance with the requirements of National Fire Protection Association (NFPA) 72. Specifically, the semi-annual visual maintenance requirements for all initiating devices of the fire alarm system were not completed. Findings include: Review on 8/28/2018 of the facility's fire alarm system inspection reports, dated 3/17/2017, 9/21/2017, and 3/16/2018, indicated there was no documented evidence of semi-annual visual inspections for all fire alarm initiating devices. During an interview on 8/28/2018 at 11:00 AM, the Environmental Services Director stated the required NFPA 72 semi-annual visual maintenance requirements for the facility's initiating devices were not completed, and was not aware of this fire alarm requirement. 2012 NFPA 101: 19.3.4.1, 9.6.1.5 2010 NFPA 72: 14.1, 14.3.1 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 10, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
A visual inspection was completed of all fire alarm initiating devices was completed on 9/5/18.
The entire system was inspected and no issues were found.
The contracted vendor (Herrtronics) was contacted on 9/1/18, their semi annual inspection will include an inspection of 50% of the devices with the Environmental Services Director completing the other 50% to insure objectivity. This will be done by 9/30/2018.
An audit of the devices will be completed and reported to the Saftey Committee and QAPI Committee by 10/24/18.
The Environmental Services Director will be responsible for the completion by 10/24/18 and ongoing.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

Based on observation and interview during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 1 isolated area (kitchen) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2 which states Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, the kitchen contained both quick response and standard response sprinkler heads. Findings include: On 8/28/2018 at 2:45 PM, a surveyor in the kitchen observed 8 standard response heads and 1 quick response head. During an interview on 8/28/2018 at 2:53 PM, the Environmental Services Director stated he was not aware the kitchen smoke zone could not contain both standard response sprinkler heads and quick response sprinkler heads. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 10, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Sprinkler vendor made inspection of the sprinkler heads for this deficiency on 9/3/18, defined plan to replace the standard heads with quick response. Access panels will be installed in ceiling at point of replacement by 9/21/18. Vendor to order replacement heads and install by 10/20/18.
All areas of facility were inspected on 9/3/18, there are no other areas where there are both standard and quick response present.
The corrective action will be reported to the Safety and QAPI Committees by 10/24/18.
The Environmental Services Director is responsible for completion by 10/24/18.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 28, 2018
Corrected date: October 24, 2018

Citation Details

Based on observation, record review and interview during the Life Safety Code survey, the facility did not ensure the building's automatic sprinkler system was tested in accordance with National Fire Protection Association (NFPA) 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Specifically, the hydraulic nameplate for the building was missing. Findings include: Review on 8/28/2018 of the facility's sprinkler system inspection reports, dated 8/11/2017, 11/6/2017, 2/12/2018, and 5/11/2018, indicated that the hydraulic nameplate for the building was not applicable. On 8/28/2018 at 3:14 PM, a surveyor in the basement observed that the sprinkler system hydraulic nameplate was missing. During an interview on 8/28/2018 at 3:14 PM, the Environmental Services Director stated he was not aware the hydraulic name plates for the sprinkler system was required, and assumed the third party sprinkler vendor would be completing all sprinkler system inspection and testing requirements. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25, 5.2.6 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedSeptember 10, 2018

This plan of correction constitutes our written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
The contractor who installed the sprinkler system was contacted on 8/31/18 and was able to locate the hydraulic nameplate, emailed a copy on 9/3/18. The actual nameplate arrived on 9/10/18 and has been installed.
The nameplate is for the entire sprinkler system.
Installation will be reported to the Safety and QAPI Committees by 10/24/18.
The Environmental Services Director will be responsible for the completion of this correction by 10/24/18.