Andrus On Hudson
September 28, 2017 Certification Survey

Standard Health Citations

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: September 28, 2017
Corrected date: October 5, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that one of four residents (Resident #99) reviewed for accidents was provided an assistive device that was properly maintained to prevent accidents. Specifically, the care planning team did not ensure that an electronic device (wander-guard) used by the resident to prevent elopement was maintained in accordance with the manufacture's guidelines to ensure proper functioning at all times when in use. The findings are: Complaint Intake Number: NY 522 Resident #99 is diagnosed with [REDACTED]. The annual elopement risk assessment dated [DATE] revealed that this resident is cognitively impaired and has poor decision- making capacity. It also revealed that the resident has prior history of elopement attempt from the facility. The care plan dated 8/24/17 noted the resident to be at risk for elopement (i.e. leaving the facility unauthorized and unknown to staff). The interventions to prevent elopement include monitoring the resident's whereabouts, involving the resident in recreation activities, and applying a wander-guard (an electronic device worn by the resident to alert staff when the resident wanders into certain unsafe and unmonitored areas). Review of a nurse's noted dated 9/17/17 revealed that the resident left the building on that date unknown to staff. The report of the investigation conducted by the facility on 9/17/17 revealed that on that date the resident, while wearing a wander-guard bracelet on her ankle, exited the facility at the main entrance without activating the wander-guard system and that staff was unaware that the resident left the building. The facility's staff was alerted when a visitor made them aware that the resident was outside the building. Further review of the investigative report revealed that an inspection of the wander-guard system showed that the tag pick up field from the knee down was weak. The report also showed that the battery for the wander-guard bracelet worn by this resident had an expiration date of (MONTH) (YEAR). The Director of Nursing was interviewed on 9/27/17 at 11:03 AM. She stated that prior to this incident, the wander-guard bracelets were not checked for expiration dates and that this oversight was corrected. An interview conducted on 9/28/17 at approximately 3:00 PM with a Sale Representative Manager for the wander-guard company revealed that there is no guarantee that after three years the battery will function and that using it beyond the expiration date put the resident's safety at risk. 415.12(h)(l)

Plan of Correction: ApprovedOctober 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective Action for Identified Residents
Resident # 99 was returned without injury on [DATE] within a few minutes after exiting. Resident # 99's wanderguard was replaced on [DATE] with a new wanderguard bracelet that expires ,[DATE]. An incident report was completed for resident #99 and her Attending Physician observed no physical or emotional adverse effect. This event was reported to DNS & Administrator on [DATE] by the RN supervisor on duty. The incident was reported to NYSDOH via HERDs on [DATE] by the DNS and case # NY 522 was assigned. The resident is to be monitored on the nursing 24 hour report for 14 days s/p elopement attempt. Resident will be encouraged not to loiter in the lobby area and to return to unit. Resident does attend off unit activities and this will be maintained for quality of life.

II. Identification of Other Residents
All other residents deemed high risk for elopement were checked on [DATE] & were observed present and safe within the facility. All wanderguard bracelets in use (18 in total) were tested and found working. All Wanderguard bracelets expirations dates were checked & 1 other resident of 18 residents deemed high risk for elopement had a bracelet that had expired. This bracelet was changed to a new bracelet with an expiration date of ,[DATE].
III. Measures and Systemic Changes
The elopement prevention policy was reviewed & revised on [DATE] to include a review of expiration dates of bracelets & replacement of bracelets prior to the expiration date. The form that lists which residents have a wanderguard bracelet, now includes not only their name, room #, location of bracelet (i.e. ankle or wrist), and tag #, now includes the expiration date of the tag. TotalKare, wanderguard company, was contacted on [DATE] to assess door sensors/roam alert sensors/voltage. TotalKare, wanderguard company came to facility on [DATE] & found a weak pickup field from the knee down at the main entrance. TotalKare adjusted sensor to Main Entrance on [DATE] & it tested as ok. An inservice on the details of the event & the elopement policy revisions was developed & was completed for all staff on [DATE].
IV. Monitoring of Corrective Actions
A daily audit of all wanderguard bracelets is done by the ,[DATE] nursing supervisor with a review of expiration dates of all bracelets. The Nursing Director checks each day to ensure the 11 - 7 supervisor has completed the audit. A daily check of door egress sensors is completed by maintenance to ensure egress door sensors are working and the Facilities Director checks each day to ensure the audit has been completed.
Audits with negative findings will have corrective actions immediately implemented by the Nursing or Facilities Director based on the finding.
Audit findings will be presented to the QAPI Committee monthly for the 1st three months for systematic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further audits.
V. Date of Correction and Person Responsible
All corrections were completed by Director of Nursing Services and the Director of Facilities on [DATE].

Standard Life Safety Code Citations

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 27, 2017

Citation Details

2012 LSC 101 7.8 Illumination of Means of Egress. 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified. 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. Based on observation and interview, the facility did not ensure that the illumination of the means of egress on a resident unit was installed and maintained in accordance with 7.8. This was evidenced by manually operated wall-mounted switches installed on the 5th floor that, when turned to the off position, turned the lights off in 4 of 4 corridors leading to the stairwell exits. This would not ensure that required and sufficient lighting would be continuously in operation and capable of automatic operation without manual intervention. The findings are: During the life safety recertification survey conducted on 9/25/17 at approximately 1:55 PM, wall mounted light switches were noted at the nurse's station on the 5th floor. When these switches were manually turned to the off position, all lights in these corridors were turned off. There are required emergency exits located in each of the corridors. In an interview at the time of the findings, the Director of Facilities stated that this current system was always in place. He further stated that the wall mounted light switches will be changed to provide continuous illumination. 2012 NFPA 101: 19.2.8, 7.8.1.1, 7.8.1.2.1, 7.8.1.4* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective Action for Cited Area:
Switch Electric was called in to evaluate how to provide continuous illumination in 4 hallways on the 5th floor. Proposal was received and approved and signed on 10/6/17.
II. Identification of other Areas:
The Dir. of Facilities completed an inspection of the entire facility to ensure all other corridors on all units and floors has the required illumination. 10/9/17
III. Measures and Systemic Changes:
1. All work will be completed by 11/27/17.
2. The Dir. of Facilities or his designee will ensure on a monthly basis all egress lighting is maintained in accordance with 7.8 of (MI)S.C.
IV. Monitoring of Corrective Actions:
All corridors on all floors will be surveyed monthly for the next 3 months to ensure that the illumination of the means of egress is maintained in accordance with 7.8 of the (MI)S.C. by the Dir. of Facilities or his designee. Audits with negative findings will be corrected immediately. Audit findings will be presented to the QAPI Committee monthly for the first 3 months for systemic evaluation and follow-up. Depending on the results, the Committee will determine the frequency of further monitoring action.
V. Date of Correction and Person Responsible:
All corrections to be completed by the Dir. of Facilities by 11/27/27

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: September 28, 2017
Corrected date: November 27, 2017

Citation Details

2012 NFPA 101 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5 2010 NFPA 13 Standard for the Installation of Sprinkler Systems 8.5.5.3.1 Sprinklers shall be installed under fixed obstructions over 4 ft ( 1.2 m) wide such as ducts, decks, open grate flooring, cutting tables, and overhead doors. 8.15.10 Electrical Equipment. 8.15.10.3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-pipe electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation and interview, the facility did not ensure that sprinklers were installed in all required areas in the facility, and that the electrical switch gear and electrical panel closets where sprinkler coverage was omitted met all required exceptions, in accordance with NFPA 101 and NFPA 13. This was evidenced by: 1. Sprinkler coverage was not provided for the area under a 4 ft. wide HVAC duct in the kitchen storage room. 2. Sprinkler coverage was lacking in the IT closets on three of four resident floors and the telephone room. 3. Two of 2 doors to the electrical switch gear room lacked fire rating plates and 2 of 8 electrical panel closets on 2 of 4 resident floors did not have a two-hour enclosure. Large openings were noted in the concrete walls of these closets. The findings are: During the life safety code recertification survey conducted on 9/25/17 and 9/26/17 between the hours of 11:00 AM and 2:30 PM, the following issues were noted: - At approximately 11:50 AM, a tour of the kitchen storage room was conducted and a 4 ft. wide HVAC duct system was noted to be installed in the room. There was no sprinkler coverage provided for several metal shelves containing canned food that was located along an exterior wall near the HVAC ducts. - At approximately 12:35 PM, a tour of the main electrical switch gear room revealed that 2 of 2 doors to the room lacked the required 90 minute fire rating. In addition, the exterior door to the room contained a glazed vision panel with an unknown fire rating. - At 12:55 PM, telephone room #B55 located in the basement was noted to lack sprinkler coverage. - On 9/26/17, at approximately 11:30 AM, an examination of the electrical panel closet located on the 3rd floor C wing revealed that the room did not have sprinkler coverage and the room lacked a 2 hour fire rated enclosure. There was an opening in the concrete in 1 of 3 walls in the room measuring approximately 12 x 4 inches wide. - At approximately 11:45 AM, a tour of the IT closet located on the 3rd floor was conducted. The room lacked sprinklers. This was also noted in the IT closets on resident floors 2 and 4. - At approximately 12:10 PM, an examination of the electrical panel closet located on the 2nd floor C wing revealed that the room lacked sprinklers and a 2 hour fire rated enclosure. There was an opening in the concrete in one of 3 walls in the room exposing the wood frame and sheet rock underneath. The opening measured approximately 18 x 8 inches wide. The Director of Facilities stated that sprinkler coverage will be installed in the areas mentioned. He further stated that the vendor will be contacted regarding the fire rating for the doors to the electrical switch gear room , and that the walls in the electrical panel closets will be sealed. 2012 NFPA 101: 19.3.5.1 2010 NFPA 13: 8.5.5.3.1, 8.15.10.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective Action for Cited Area:
S&S Fire Suppression System was called on 9/28/17 to evaluate the needed repairs. Walkthrough completed on 9/29/17. A repair agreement was sent on 10/2/17 and evaluated by the Dir. of Facilities. Contract was signed on 10/6/17 and work started on 10/9/17
II. Identification of Other Areas:
The Dir. of Facilities completed an inspection of the entire facility to ensure the automatic sprinkler system is in accordance with NFPA 101 and NFPA 13. Completed 9/29/17.
III. Measures and Systemic Changes:
1. Sprinkler coverage will be installed under 4 feet wide HVAC duct in the kitchen storage room. Completed 10/9/17.
2. Sprinkler heads are being installed in the I.T. closets on the 2,3 & 4th floor D wings.
3. Sprinkler head has been installed in the telephone room on the lower level (B55). Completed 10/10/17.
4. Outside vendor has been called to evaluate the two doors of the switch gear room to ensure a rating of 90 minutes. Also to ensure a rating on the doors glazed vision panel. If doors do not meet fire rating standards, they will be replaced with those that do. Contract signed on 10/11/17.
5. 2nd floor and 3rd floor C wing electrical closets will be properly sealed with a 2 hour fire rated enclosure.
IV Monitoring of Corrective Action:
The Dir. of Facilities or his designee will inspect all electrical closets to ensure a 2 hour fire rated enclosure is maintained. These inspections will be done on a monthly basis for 3 months. Audits with negative findings will be presented to the QAPI Committee monthly for the first three months for systemic evaluation and follow-up. Depending on results, the Committee will determine the frequency of further monitoring activities.
V. Date of Correction and Person Responsible:
The Dir. of Facilities or designee will try to complete all corrections by 11/27/17. Due to the facility's reliance on an outside vendor to complete the work, the facility might require an extension beyond the 60th day from the survey exit date.

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: September 28, 2017
Corrected date: November 27, 2017

Citation Details

2011 NFPA 25 Chapter 2-2.1.1 Sprinklers. 5.2.2* Pipe and Fittings. Sprinkler pipe and fittings shall be inspected annually from the floor level. 5.2.2.1 Pipe and fittings shall be in good condition and free of mechanical damage, leakage and corrosion. and misalignment. 5.2.2.2 Sprinkler piping shall not be subjected to external loads by materials either resting on the pipe or hung from the pipe. Chapter 8 Fire Pumps 8.3* Testing 8.3.1. Frequency 8.3.1.2* Electric- motor driven fire pumps shall be operated monthly. 8.3.2.3 The electric pump shall run a minimum of 10 minutes. 8.3.2.8 The pertinent visual operations or adjustments specified in the following checklists shall be conducted while pump is running: (2) Electrical system procedures as follows: (a) Observe the time for motor to accelerate to full speed (b) Record the time controller is on first step (for reduced voltage or reduced current starting) (c) Record the time pumps runs after starting (for automatic stop controllers). Based on observation, documentation review, and staff interview, the facility did not ensure that the automatic sprinkler system was maintained in accordance with NFPA 25 as evidenced by: 1. Data cable wires, a fan and a light fixture were secured to the sprinkler pipes in a storage room, the fire pump room, and the painters room. 2. The monthly churn test for the fire pump was not exercised for the required duration. The findings are: During the life safety recertification survey conducted on 9/25/17 between the hours of 11:00 AM and 2:30 PM, the following issues were noted: 1. Data cable wires, a fan and a light fixture were secured to the sprinkler pipes in a storage room, the fire pump room, and the painters room. - At approximately 12:20 PM, a tour of the storage room revealed data cables secured to the sprinkler pipe. - At approximately 12:20 PM, a tour of the fire pump room located on the D wing was conducted and a light fixture in the room was noted to be secured to the sprinkler pipe. -At approximately 12:25 PM, a tour of the painters room was conducted and a fan was noted to be attached to the sprinkler pipe. 2. The monthly churn test for the fire pump was not conducted for the required duration of 10 minutes. On 9/26/17 at approximately 10:05 AM, the monthly reports for the electric motor driven fire pump were reviewed and it was noted that the fire pump was exercised for only 3 minutes and not the required 10 minutes. In an interview at the time of the findings, the Director of Facilities stated that the items attached to the sprinkler pipes will be removed. The Director of Facilities stated that the fire pump was exercised for 3 minutes to ensure that the pump was operational, but that he will start exercising it for ten minutes. 2011 NFPA 25: 5.2.2*, 5.2.2.1, 5.2.2.2, 8.8.5.1.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective Action for Cited Area:
1. All data cable wires, fans and light fixtures were removed from Sprinkler pipes. Completed 9/29/17.
2. The monthly Churn Test will be conducted for the required 10 minutes per code NFPA 25. This started on 10/11/17.
II. Identification of Other Areas:
The Dir. of Facilities completed an inspection of the entire facility to ensure the automatic sprinkler system is maintained in compliance with NFPA 25. Completed 9/29/17.
III. Measure and Systemic Changes:
1. All cables were cut from sprinkler pipes 9/29/17.
2. Fan was removed from sprinkler pipe 9/29/17.
3. Light was removed from sprinkler pipe 9/29/17
4. Monthly Churn test of fire pump is now tested for 10 minutes per NFPA 25.
5. In-service will be provided to staff to educate them on NFPA 25 requirements.
IV. Monitoring of Corrective Action:
The Dir. of Facilities or his designee will do a monthly check for three (3) months throughout the building to ensure compliance with NFPA 25. Audit findings will be presented to the QAPI Committee monthly for a minimum of three (3) months. Depending on the results, the committee will determine the frequency of future monitoring of action.
V. Date of Correction and Person Responsible
All corrections to be completed by 10/31/17 by the Dir. of Facilities.

K307 NFPA 101:UTILITIES - GAS AND ELECTRIC

REGULATION: Utilities - Gas and Electric Equipment using gas or related gas piping complies with NFPA 54, National Fuel Gas Code, electrical wiring and equipment complies with NFPA 70, National Electric Code. Existing installations can continue in service provided no hazard to life. 18.5.1.1, 19.5.1.1, 9.1.1, 9.1.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 28, 2017
Corrected date: November 27, 2017

Citation Details

2011 NFPA 70 National Electrical Code Article 110.12 Mechanical Execution of Work. Electrical equipment shall be installed in a neat and workmanlike manner. (B). Integrity of Electrical Equipment and Connections. Internal parts of electrical equipment, including busbars, wiring terminals, insulators, and other surfaces shall not be damaged or contaminated by foreign materials such as paint, plaster, cleaners, abrasives, or corrosive residues. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as parts that are broken; bent; cut; deteriorated by corrosion; chemical action, or overheating; or contaminated by foreign materials such as paint, plaster, cleaners, or abrasives. Article 408 Switchboards and Panelboards 408.4 Field Identification Required. (A) Circuit Directory or Circuit Identification. Every circuit and circuit identification modification shall be legibly identified as to its clear, evident, and specific purpose or use. The identification shall include sufficient detail to allow each circuit to be distinguished from all others. Spare positions that contain unused overcurrent devices or switches shall be described accordingly. The identification shall be included in a circuit directory that is located on the face or inside of the panel door in the case of a panelboard, and located at each switch or circuit breaker in a switchboard. No circuit shall be described in a manner that depends on transient conditions of occupancy. Based on observation and interview, the facility did not ensure that the internal parts of electrical equipment and the circuit directory was clear and evident to a specific purpose. This is evidenced by the directory in the electrical panel closets that were not clearly identified on the circuit breaker and the protective covers to a junction box and a conduit in the electrical panel closets that were missing. The findings are: During the life safety recertification survey conducted on 9/26/17 between the hours of 10:30 AM and 2:30 PM, the following was noted: - At approximately 10:45 AM, a tour of the the electrical closet on the 4th floor D wing was conducted and it was noted that a circuit directory was missing from the panelboard labeled 4 A. In addition, the switches for the lights were not readily identifiable in the directory, as evidenced by the Director of Facilities needing to test numerous switches before identifying the proper switch for the lights. - At approximately 11:15 AM, a tour of the electrical panel closet on the 3rd floor B wing revealed that the cover plate to the junction box for the wires leading into the emergency panel board was missing. - The electrical panel closet on the 3rd floor C wing was toured at approximately 11:30 AM, and it was noted that a cover plate was missing for the conduit, resulting in the wires being exposed. - At approximately 12:35 PM, a tour of the electrical panel closet on the 2nd floor C wing was conducted. At that time, the circuit directory was noted to be outdated in that the marking on the panel board did not correspond with the information on the circuit directory. In an interview at the time of the findings, the Director of Facilities stated that the circuit directories will be updated. He further stated that the cover plates to the junction box and the conduit will be installed. 2012 NFPA 101: 19.5.1.1, 9.1.2 2011 NFPA 70: Article 110-12 (B), Article 408.4(A) 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedOctober 12, 2017

I. Corrective Action for Cited Area:
A circuit directory will be created for the panelboard labeled 4A in the 4th floor D wing electrical closet. Switches for lights will be labeled in the directory.
The cover plate to the junction box for the wires leading into the emergency panel board will be installed in the electrical panel closet on the 3rd floor B wing.
The cover plate for the conduit will be installed in the electrical panel closet on the 3rd floor C wing. Wires are no longer exposed.
The circuit directory was updated in the panel board in the electrical panel closet on the 2nd floor C wing.
II. Identification of Other Areas:
The Director of Facilities completed an inspection of the electrical closets on all units to ensure all panel boxes were labeled and in accordance with the directory and all cover plates were in place.
III. Measures and Systematic Changes:
Once labels are corrected, a second copy will be held in a book in the Dir. of Facilities' office, so if a label goes missing, the directory will be referred to so another label can replace the missing one. Additionally, electrical closets will be surveyed monthly to ensure that internal parts of electrical equipment and the circuit directory are clear and evident.
IV. Monitoring of Corrective Actions:
All electrical closets will be surveyed monthly for the next 3 months to ensure internal parts of electrical equipment are intact as are the labels on the panels by the Dir. of Facilities or his designee. Audits with negative findings will be corrected immediately. Audit findings will be presented to the QAPI committee monthly for the first 3 months for systemic evaluation and follow-up. Depending on the results, the committee will determine the frequency of further monitoring activities.
V. Date of Correction and Person Responsible
Corrections to be completed by 11/27/17 by the Dir. of Facilities.
This plan of correction constitutes the facility's written credible 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 Federal and State laws.