Loretto Health and Rehabilitation Center
June 29, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.24(a)(1)(b)(1)-(5)(i)-(iii):ACTIVITIES DAILY LIVING (ADLS)/MNTN ABILITIES

REGULATION: §483.24(a) Based on the comprehensive assessment of a resident and consistent with the resident's needs and choices, the facility must provide the necessary care and services to ensure that a resident's abilities in activities of daily living do not diminish unless circumstances of the individual's clinical condition demonstrate that such diminution was unavoidable. This includes the facility ensuring that: §483.24(a)(1) A resident is given the appropriate treatment and services to maintain or improve his or her ability to carry out the activities of daily living, including those specified in paragraph (b) of this section ... §483.24(b) Activities of daily living. The facility must provide care and services in accordance with paragraph (a) for the following activities of daily living: §483.24(b)(1) Hygiene -bathing, dressing, grooming, and oral care, §483.24(b)(2) Mobility-transfer and ambulation, including walking, §483.24(b)(3) Elimination-toileting, §483.24(b)(4) Dining-eating, including meals and snacks, §483.24(b)(5) Communication, including (i) Speech, (ii) Language, (iii) Other functional communication systems.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview during the recertification and abbreviated surveys (NY 179), the facility did not ensure care received was consistent with the resident's needs and choices for 1 of 8 residents (Resident #245) reviewed for activities of daily living (ADLs). Specifically, there was no documentation Resident #245 was provided ambulation as planned. In addition, the resident waited an extended period for assistance from staff with dressing. Findings include: Resident #245 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The 05/31/18 Minimum Data Set (MDS) assessment documented the resident was cognitively intact and required extensive assistance with walking in the room, in the corridor, and with dressing. The 02/20/18 comprehensive care plan (CCP) documented the resident was dependent on 2 staff for clothing management, and was to ambulate 20 feet twice daily (BID) with staff. Staff were to keep the resident's call bell in reach at all times and provide assistance with ambulation per physical therapy (PT) recommendation. The 04/26/18 PT discharge summary documented the resident would be on a unit ambulation program, she required contact guard to minimum assistance of 1 for transfer, and was to ambulate 25-40 feet using a wheeled walker with stand by guard. Between 04/28-05/01/18 there was no documentation staff were ambulating the resident 25-40 feet as recommended by PT. A nursing progress note documented on 05/01/18 that a trigger (a request for physical or occupational therapy assessment of a resident) was sent to PT this date as the resident wanted to see if she could walk again and needed to be re-assessed for transfer status. There was no documented follow up to this nursing trigger. A physical therapy nursing plan of care documented on 05/22/18 the resident was evaluated after a fall and the physical therapist recommended ambulating the resident BID at least 20 feet. The resident would be started on a PT program for ambulation and transfers. The CCP was updated on 06/22/18 and documented the resident was now dependent on 1 staff for clothing management and was to walk with staff 50 feet BID. The 06/22/18 certified nurse aide (CNA) care instructions documented the resident was to be ambulated 50 feet BID with stand by assist of 1. The CNA ADL form dated between 06/21/18-06/26/18 had no documentation the resident was offered or provided ambulation on the day or night shift. The evening shift noted only 3 of 6 days the resident required extensive assistance with walking. The ADL record had no documentation how many feet the resident walked when she did walk in the corridor or in her room. Specifically, on 06/16/18 the 07:00-03:00 PM CNA noted walking did not occur on that shift. The resident was observed by a surveyor in her room with her call light lit on the outside of her door at 06/26/18 at 02:25 PM. The surveyor entered the room and sat down with the resident. Within 2 minutes a transport staff came to the room and asked the resident if she was coming to therapy. The resident stated she was going to come, her pants she had on were too big and would fall down, and she was waiting for staff to come in and help her change them before she went to therapy. The transport person stated ok, he would see her later, and left the area. During an interview with the resident on 06/26/18 at 02:27 PM, while the resident's door remained open, she stated the staff were supposed to walk her on the unit and they did not. She stated they were often short staffed and would tell her they did not have time to walk with her. She often had to wait an extended period of time for staff to help her. She stated, like now for instance, she was waiting for her pants to be changed so she could participate in therapy. She stated her aide was assigned to monitor the lounge and was not able to leave the lounge area to assist her. The aide would not be able to assist her until the next shift came on at 03:00 PM. The surveyor stayed with the resident through 02:54 PM and no staff came in and offered assistance to the resident or responded to her call light from within the room. During a follow up interview with the resident on 06/27/18 at 11:35 AM, she stated it ended up being too late to go to therapy on 06/26/18. The aide did not assist her until the next shift came in at 03:00 PM. During an interview with CNA #8 on 07/02/18 at 10:20 AM, she stated the resident required extensive assistance with dressing, including assisting her with her pants. She stated the resident liked to walk with her to and from the bathroom. Sometimes after meals she would ring the call bell for assistance. The resident was on an ambulation program and she would walk the resident after lunch. The CNA stated she was to document in the ADL documentation record. She stated she would check off that ambulation was provided, and would not do anything if ambulation was not provided. She stated she was not able to enter how many feet the resident did or did not walk. She stated it was not part of the resident's plan to notify the nurse if the resident declined or staff were unable to provide documentation, but staff should notify the nurse in charge. She stated sometimes the resident wanted to walk, sometimes she did not and she was not sure of any specifics of who she had told that to. During an interview with Assistant Director of Nursing (ADON) #3 on 07/02/18 at 11:03 AM, she stated the resident had been on and off a physical therapy program over time. She was covering as the Unit Manager for the resident's unit currently and she did not know her well. She stated it would be on the resident's assignment sheet if she was on an ambulation program. It should be documented in the CNA ADL record if the staff provided ambulation. The staff were not able to document the amount of feet someone walked. She stated if a resident declined or there was a concern with the ambulation CNAs should notify the nurse who would document it. When a staff person was assigned to the lounge area the other CNAs on the unit should be monitoring call bells. She stated over 20 minutes was too long for the resident not to be approached to see what she needed and the resident should have been assisted more timely. The 06/26/18 CNA assignment sheet documented CNA #10 was documented as assigned to providing care to the resident for the 07:00-03:00 PM. The assignment sheet noted CNA #10 was assigned to monitor the lounge from 02:00 PM-02:30 PM. During an interview with CNA #10 on 07/02/18 at 12:11 PM, she stated the resident required assistance with dressing her lower body. She was on an ambulation program on the unit could walk. She stated sometimes the resident walked to the dining room, sometimes she only walked to her bathroom, and sometimes she did not walk at all per choice. The CNA stated she would sign off in the electronic record that ADL care was completed, but there was no way to document that a resident refused, did not walk, or only walked a limited number of steps. She stated if the resident walked only 10 feet instead of 50, she would mark off that the resident completed her ambulation. On the nursing units certain staff were required to monitor the resident lounge areas and still have a care assignment. While monitoring the lounge, other staff were supposed to monitor call bells and assist residents on the care assignments. Once in a while the resident would request to be changed after lunch and she picked out her own outfits. Sometimes the resident would say her clothing did not fit, she was not able to change herself and staff would have to assist her. She did not recall any specifics for 06/26/18 related to the resident's care needs and requests. During an interview with physical therapist #9 on 07/02/18 at 12:53 PM, she stated the resident was on a restorative therapy program. She stated the resident had been referred to therapy and the resident's prior status of ambulation had declined since she was last on a PT program. She stated when someone was discontinued from therapy the therapy staff always sent a plan for the staff on the unit. Following her last discharge PT had recommended staff ambulate the resident 50 feet BID on the unit. She stated once the resident is discharged from PT they would send a program plan to the unit and it was then nursing responsibility to ensure the resident was walking the full distance or not, and notify therapy if there were changes. The CNAs were to record if ambulation was provided, and she was not sure if the CNAs were able to record how many feet a resident walked. 10NYCRR 415.12(a)(1)(i,ii)

Plan of Correction: ApprovedJuly 20, 2018

1) Resident #245: The CNA assignment sheet was reviewed for accuracy to ensure the appropriate therapy recommendations including how often and how far the resident is to ambulate is correctly reflected. Resident #245 ambulation is 50ft BID assist of one with wheeled walker. The resident is currently not ambulating per her plan of care per resident choice. Currently ambulating 20ft at least twice in her room per her resident choice.
The transport staff member received re-education regarding the expectation to notify appropriate staff of resident needs.
2) All care plans and CNA assignment sheets for residents on an ambulation program will be reviewed to ensure for accuracy per therapy recommendations.
3) The ambulation program: Walk Around the Clock policy was reviewed and revised to reflect the expectation for CNA staff to report to LPN/RN/Charge Nurse any refusals or inability to perform the recommended therapy ambulation program. The RN/LPN/Charge nurse will document in resident EMR any refusal or inability to ambulate per plan of care.
The Call (NAME) policy and procedure was reviewed.
Licensed nursing staff and CNA?s will receive education on the newly revised ambulation program: Walk Around the Clock policy and receive re-education on the Call (NAME) policy.
The Routine Care Planning Guide policy has been reviewed. All Nurse Managers and MDS coordinators responsible for care planning will receive re-education on the policies to ensure accuracy of the recommended therapy program.
4) Weekly therapy liaison walking rounds will review resident?s ambulation program to ensure residents are able to perform the recommended therapy ambulation program.
The nurse manager will complete monthly audits, including discussion with staff, to ensure the residents are able to perform the recommended therapy ambulation program and if resident has had a change in ambulation status the appropriate documentation and follow up is indicated in the EMR per facility policy. The Optimus ADL Walking report will be run weekly on all resident?s on an ambulation program to ensure documentation is accurate and completed.
The call bell system will be audited by the DON/ADON weekly to ensure the policy is followed. If call bell is out of compliance the nurse manager will follow up with the responsible staff and ensure plan of correction is put in place. In addition, monthly auditing will be conducted by the operations manager to ensure residents are receiving the assistance they are needing in a timely manner.
5) These audit will be completed monthly on all nursing units for a minimum of three 3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality assurance Meetings to assure compliance is met and reoccurrence is prevented. The Quality Assurance committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period. The date for correction is 8/25/18. The Director of Nursing is responsible to ensure continued compliance.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview during the recertification survey the facility did not ensure 1 of 2 residents (Resident #318) reviewed for care planning had a comprehensive person-centered care plan for each resident consistent with the resident's mental and psychosocial needs. Specifically, Resident #318 did not have a person-centered care plan to address his behaviors and use of anti-psychotic medications. In addition, the resident had inconsistent documentation on the [DIAGNOSES REDACTED]. Findings include: Resident #318 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The resident required limited to extensive assistance with most activities of daily living (ADLs). The portion of the MDS listing psychiatric/mood disorders documented the resident had depression and did not have any additional psychiatric or mood disorders. The 08/24/17 admission physician's orders [REDACTED]. A 10/03/17 social services progress note the resident was seen going in to another resident's room and he was counseled about inappropriateness of physical contact with female peers that had dementia. He stated he understood. The 10/05/17 comprehensive care plan (CCP) documented the resident had inappropriate behaviors with another resident. Staff were to provide 15-minute checks. The resident was alert, oriented, independent in decision making and was adjusting to the facility. The resident had [MEDICAL CONDITION] drug use related to [MEDICAL CONDITION] and agitation. The CCP was updated on 10/16/17 to include change to intensive supervision (a staff person sits 1:1 with him 24 hours/day) to be provided by staff. The CCP did not include person-centered interventions to address the resident's adjustment to the facility, plan for use of [MEDICATION NAME], or monitoring and addressing resident behaviors. A plan was not implemented to monitor the resident's adjustment to the use of intensive supervision. A 10/07/17 at 01:46 PM nursing progress note documented the resident had attempted to make contact with a female resident in another room. The resident was seen in her room wanting to assist her in bed and was later seen rubbing her arm in a common area. At 11:02 PM, the resident was in a female resident's room. On 10/11/17 at 3:49 PM, a nursing progress note documented the resident allowed a female resident in to enter his room while he was in the room. A 10/16/17 at 11:09 AM social services progress note documented the resident was alone with a female peer in his room with the door shut. The social worker reminded the resident he had been counseled about staying away from the resident, more specifically, arm's length away. Nursing progress notes documented on 10/23/17 at 03:07 PM, the resident yelled at staff, accused them of staring and was upset that someone was watching over him. On 10/24/17 at 12:57 PM, the resident had been agitated lately, and threatened to throw non-food items from his meal tray. A 11/14/17 physician progress notes [REDACTED]. A 12/22/17 psychiatric nurse practitioner (NP) consult documented the resident was on [MEDICATION NAME] for restlessness and agitation. A 05/22/18 physician progress notes [REDACTED]. The resident had sexual inappropriateness. The resident was observed in his room alone with a staff person acting as 1:1 outside of the door. At times the door was open at times it was closed and he was in the room alone: On 06/26/18 at 01:23 PM, on 06/27/18 at 11:39 AM; and on 06/28/18 at 02:14 PM. During an interview with CNA #14 on 07/02/18 at 10:10 AM, she stated the resident always stayed in his room and did not leave the floor. She stated he would come out for meals and sit by himself per his choice. She stated he was on 1:1 related to an incident at the facility when he touched another resident inappropriately. She stated the resident had thrown silverware at someone and now had paper products at meals. She stated this was not listed on his care instructions but it was on his meal tickets. She was responsible for answering his call bell, and assisting him when needed. She would sit outside the door and get up and take notes every hour on where he was in his room and what he was doing. She had not been instructed otherwise. During an interview with CNA #8 on 07/02/18 at 10:20 AM, she stated when the resident first arrived at the facility he was touchy with another female resident. She stated 1:1 was implemented after this. She stated he did not seem to have any incidents since, and he knew he was being monitored now. She stated he comes out for meals and immediately goes back to his room. She stated he would be confused to what time it was only when he would nap through the day and wake up at varying times. He responded to others how they responded to him. During an interview with CNA #15 on 07/02/18 at 10:35 AM, he stated the resident stayed in his room a lot. When he provided 1:1 he would sit outside the resident's door and the resident would call him when needed. The resident was on 1:1 related to being intimate with another resident. The resident did not have any hallucinations, delusions or behaviors towards others. During an interview with CNA #16 on 07/02/18 at 10:54 AM, she stated the resident kept to himself and he would converse with others who conversed with him. He only came out of his room for meals. He would turn on his call bell when he needed something. The resident was placed on 1:1 as staff saw the resident in another room with a resident without clothing on. During an interview with ADON #3 on 07/02/18 at 11:03 AM, she stated 1:1 was started in 10/2017 related to an inappropriate interaction with a female resident. She stated she was not aware of two instances with a female resident and that resident was not oriented. The resident did not present with any mental health symptoms. The resident was on [MEDICATION NAME] for restlessness per the record since 08/2017. She reviewed provider notes and stated the psychiatric nurse practitioner (NP) documented the resident had [DIAGNOSES REDACTED]. She stated she did not know the reason for these [DIAGNOSES REDACTED]. The resident would stay on 1:1 related to history of sexual inappropriateness. It was the responsibility of the team to come up with approaches and interventions. She stated the nurse Manager that had been working on the floor no longer worked at the facility, she was covering as manager and had not had time to look at the resident's care plan to check interventions for behaviors. During an interview with social worker #17 on 07/02/18 at 11:47 AM, she stated the resident had a difficult home situation prior to coming to the facility and he required a lot of assistance and adjustment when he first arrived to determine placement and finances. She stated the resident and a female resident had kissed one another, they were separated and he was told to stay arm's length away from her. Then there was an incident that followed that he welcomed her into his room. The social worker stated she thought he had a mental health diagnosis, maybe depression or [MEDICAL CONDITION], but he did not present with any [MEDICAL CONDITION] symptoms. She was not sure where the [DIAGNOSES REDACTED]. The interdisciplinary team was responsible for managing care planned interventions. If inappropriate behaviors or a new [DIAGNOSES REDACTED]. The approaches were pre-populated and the team could make updates if needed. She was not sure if changes had been made to the resident's care plan outside of 1:1. 10NYCRR 415.11(c)(1)

Plan of Correction: ApprovedJuly 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Resident #318 care plan was updated to address his behaviors and use of antipsychotic medications and [DIAGNOSES REDACTED].?s adjustment to the facility care plan has been developed to monitor resident adjustment to use of intensive supervision and will be reviewed during care plan meetings.
2) Any resident on an antipsychotic medication or any resident exhibiting any behaviors regardless of antipsychotic use will have care plan assessed for person centered interventions. Their care plan assessed by the nurse manager to ensure it is person centered and use of antipsychotic medications are consistent with [DIAGNOSES REDACTED].
3) The facilities policies on [MEDICAL CONDITION] Medication-Unnecessary Drugs and Routine Care Planning Guide have been reviewed. All Nurse Managers and MDS coordinators responsible for care planning will receive re-education on the policies to ensure care plans are person centered, reflect resident behaviors, and addresses the resident behaviors, use of antipsychotics, consistency of [DIAGNOSES REDACTED].
4) Audits will be completed monthly by ADON?s to ensure care plans are person centered, reflect resident behaviors, addresses the resident behaviors, use of antipsychotics, consistency of [DIAGNOSES REDACTED].
5) This audit will be completed monthly on all nursing units for a minimum of three 3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings monthly to assure compliance is met and reoccurrence is prevented. The Quality Assurance committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period. The date for correction is 8/25/18. The Director of Nursing is responsible to ensure continued compliance.

FF11 483.12(c)(2)-(4):INVESTIGATE/PREVENT/CORRECT ALLEGED VIOLATION

REGULATION: §483.12(c) In response to allegations of abuse, neglect, exploitation, or mistreatment, the facility must: §483.12(c)(2) Have evidence that all alleged violations are thoroughly investigated. §483.12(c)(3) Prevent further potential abuse, neglect, exploitation, or mistreatment while the investigation is in progress. §483.12(c)(4) Report the results of all investigations to the administrator or his or her designated representative and to other officials in accordance with State law, including to the State Survey Agency, within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview during the recertification survey the facility did not ensure 1 of 9 residents (Resident #8) reviewed for abuse had complete and thorough investigations. Specifically, it was reported Resident #8's legs were debrided (removal of dead or damaged tissue) by unqualified staff that caused an increase in pain and the facility did not complete an investigation to determine if abuse, neglect, or mistreatment occurred. Findings include: The 10/10/17 Abuse Policy documented investigations of alleged incidents of abuse must be initiated immediately upon discovery. The involved staff will not be scheduled to work pending further investigation if abuse, neglect or mistreatment is suspected. Resident #8 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) assessment documented the resident was cognitively intact, required extensive assistance for most activities of daily living, had impairment to both her lower limbs, the resident was having occasional pain, and did not have any ulcers, wounds or skin problems. The 12/19/17 comprehensive care plan (CCP) documented the resident was non-ambulatory and dependent on staff to transfer. The resident had the potential for alteration in skin integrity related to poor circulation and had moisturizing lotion applied to her bilateral legs. The resident had bilateral stasis ulcers to her lower extremities that were red, scabbed, dry, and flaky. The resident had a history of [REDACTED]. The 02/23/18 skin report documented a 1st recording of a new site. The resident's bilateral lower extremities had pinkened skin with multiple scabs, blebs (small blisters), and open wounds. The wound beds were pink and weeping clear fluid. The resident was ordered Vashe (wound cleanser), [MEDICATION NAME] (ointment), and her legs were to be wrapped with Kerlix gauze daily. The 02/2018 treatment administration record (TAR) documented nursing was to apply dimethicone (skin protectant) to the resident's bilateral lower extremities twice daily (BID) through 02/23/18 when the order was discontinued, and no-sting skin prep (liquid film skin protectant) to open areas and scabs on right lower extremity once daily until healed through 02/28/18 when the order was discontinued. On 02/23/18 the TAR documented to cleanse the bilateral lower extremities with Vashe, pat dry, apply [MEDICATION NAME] ointment to the skin and wrap with Kerlix daily. This order was discontinued and replaced with a new order on 02/26/18 that documented to cleanse bilateral lower extremities with Vashe, pat dry, apply Vaseline to skin, and wrap with Kerlix daily. The TAR was updated on 02/28 and documented to the 02/26/18 treatment especially denuded areas. A registered nurse (RN) progress note written by RN Unit Manager #1 documented on 02/23/18 she received a call from nurse practitioner (NP) #2 regarding the resident's bilateral lower extremities, there were weepy open areas, and a new order was obtained for treatment to legs. A 02/28/18 provider note documented by NP #2 noted the resident's scabs on her legs secondary to her [MEDICAL CONDITION] and diabetes were debrided by an agency nurse. The resident was having a great deal of pain from the open areas. She would change the dressing, liberally apply Vaseline and [MEDICATION NAME] to the biggest open areas, and increased her routine [MEDICATION NAME] TID to four times daily (QID) until this was under control. The 02/2018 Medication Administration Record [REDACTED]. The resident received Tylenol on 02/28/18 at 04:30 AM. The MAR indicated [REDACTED]. During an interview with the resident on 06/26/18 at 10:38 AM, she stated 3-4 months ago she had stasis ulcers to her legs. An agency licensed practical nurse (LPN) on an evening shift debrided her legs and pulled skin off her legs. She had to have an increase in two different pain medications for a month. The pain was excruciating and she would lie in bed and cry at night. On 06/29/18 the surveyor requested from administration any investigations or incident reports relating to the resident during 02/2018. On the same date, the surveyor was notified there were no investigations for this resident during that time. During an interview with RN Unit Manager #1 on 06/29/18 at 04:00 PM, she stated she had went into the resident's room to do skin treatments one morning. The resident's legs looked different, they were red and the areas on her legs were not the same. The resident told the RN the night nurse had pulled some of her scabs off. The resident stated the nurse had a pile of wet wash clothes, washed her legs up and down, and the scabs were coming off as she washed her legs. The RN stated the resident had leg stasis ulcers and creams that required application. She notified NP #2 that the LPN washed the resident's legs, and she notified Assistant Director of Nursing (ADON)s #3 and 4 as they addressed agency staff. The NP came up to see the resident and implemented a treatment and increased her pain medication from TID to QID for discomfort. The NP was not pleased the scabs had been opened by the LPN. She did not look in to the incident and did not know the name of the agency LPN. During an interview with NP #2 on 07/02/18 at 12:23 PM, she stated the resident had chronic inflammation and terrible circulation to her legs. She had chronic scabs that were being treated topically. She stated she went to see the resident's legs and the resident specifically told her that an LPN debrided her legs. The NP stated when she last had seen the resident's legs there were scabs on them and on this visit they were not there. The removal of the scabs caused a great deal of discomfort to the resident as she had open sores and the NP ordered new treatments to the legs. She stated RN Unit Manager #1 had been made aware. The NP did not know who the nurse was as she thought it was a nurse on an overnight shift. She stated there was not an order in place to remove scabs and it should not have occurred. The resident had stated to the NP that it had taken some time for the LPN to wash her legs and that was not necessary if she was just washing them. The NP stated she wrote a note about it in 02/2018 and no one else at the facility had approached her about it or asked for her input. She thought an investigation had been implemented. It took the resident a month to six weeks to heal. She increased her [MEDICATION NAME] from TID to QID until healed. During an interview with ADON #3 on 07/02/18 at 11:03 AM, she stated she heard about a concern with an LPN and the resident. She could not recall how she was made aware of the concern. She stated RN Unit Manager #1 had stated that an LPN had washed the resident's legs, the scabs came off, and the Manager asked NP #2 to look at them. She stated the resident was alert and oriented. She had not seen the resident's legs. She stated the LPN was an agency nurse and she did not recall her name. She did not complete an investigation to determine if the removal of the scabs was intentional. She did not attempt to talk to the agency nurse or the NP and she was not sure if anyone else did. During an interview with ADON #4 on 07/02/18 at 01:09 PM, she stated she heard about the concern relating to an agency staff removing scabs from the resident's legs. She stated she did not see the resident or her legs, she did not talk to the resident, the nurse or the NP, she did not look in to it to determine if the removal of the scabs was intentional and she did not know if anyone else did. She did not recall the name of the agency LPN. 10NYCRR 415.4(b)

Plan of Correction: ApprovedJuly 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Resident #8 was assessed on 5/2/18 by NP. The open areas on the resident?s legs secondary to [MEDICAL CONDITION] are scabbed and it was noted that the areas ?were much improved?. The resident?s pain management has been monitored for effectiveness and resident is currently 0/10. Resident?s treatment orders to bilateral lower legs has been changed to include the instructions to ?gently cleanse? the legs.
2) The last 3 months of incident reports will be reviewed by the Vice President of Clinical Skilled Nursing, Director of Nursing and Assistant Directors of Nursing to ensure other resident were not affected.
3) The VP of Clinical Skilled Nursing reviewed the policy and procedure for Abuse, Neglect, Mistreatment, Misappropriation and Exploitation with the DON, ADON? and Nurse Managers. The DON and ADON?s will discuss any questionable abuse allegations with the VP of Clinical Skilled Nursing. The medical staff will receive education if there is a concern regarding abuse, neglect, mistreatment, misappropriation and exploitation they are to follow-up with the DON and/or ADON.
4) Audits will be a completed by the DON & ADONs monthly of all incident reports completed by the Nurse Managers on each unit, to ensure investigations were completed on incident reports found to be questionable.
5) This audit will be completed monthly on all nursing units for a minimum of three 3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings monthly to assure compliance is met and reoccurrence is prevented. The Quality Assurance committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period. The date for correction is 8/25/18. The Director of Nursing is responsible to ensure continued compliance.

FF11 483.25(g)(1)-(3):NUTRITION/HYDRATION STATUS MAINTENANCE

REGULATION: §483.25(g) Assisted nutrition and hydration. (Includes naso-gastric and gastrostomy tubes, both percutaneous endoscopic gastrostomy and percutaneous endoscopic jejunostomy, and enteral fluids). Based on a resident's comprehensive assessment, the facility must ensure that a resident- §483.25(g)(1) Maintains acceptable parameters of nutritional status, such as usual body weight or desirable body weight range and electrolyte balance, unless the resident's clinical condition demonstrates that this is not possible or resident preferences indicate otherwise; §483.25(g)(2) Is offered sufficient fluid intake to maintain proper hydration and health; §483.25(g)(3) Is offered a therapeutic diet when there is a nutritional problem and the health care provider orders a therapeutic diet.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey the facility did not ensure 1 of 6 residents (Resident #227) reviewed for nutrition, maintained acceptable parameters of nutritional status. Specifically, Resident #227 was not reassessed timely following a significant weight loss. Findings include: Resident #227 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/17/17 Minimum Data Set (MDS) assessment documented the resident was severely cognitively impaired, required supervision with eating, and did not have any significant weight changes. The 02/09/18 MDS documented the resident had a significant weight loss that was not physician prescribed. A 11/20/17 dietetic technician progress note documented the resident weighed 110.7 pounds, had not had any significant weight loss, and the resident's weight goal was 110-120 pounds. The technician observed a resident's meal, the resident would feed herself when it was placed in her hand, had decreased intake, and she would add super pudding at supper as the resident loves her sweets. The 11/30/17 comprehensive care plan (CCP) documented the resident was at nutritional risk and required extensive assistance with eating. Staff were to monitor percentage of consumption for meals, nourishments, and monitor weight. The CCP was updated on 02/12/18 and documented the resident had a significant weight loss at 90 and 180 days and an intervention (unspecified) was in place. The weight record documented the resident weighed: - 109.4 on 12/04/17 (1.3 pounds/1.17% loss in one month); - 101.0 on 01/08/18; - 101.4 on 01/10/18 (9.3 pounds since 11/2017/-8.4% loss in 2 months and -7.3% in 1 month); and - 102.2 on 02/12/18. Nurse practitioner progress notes dated 12/18/17 and 1/16/2018 documented she had not received any reports of any changes in condition over the last 30 days. There was no documentation by nutritional staff between 12/09/17 and 02/11/18. A 02/12/18 registered dietitian (RD) progress note documented the resident had weighed 110.7 pounds in 11/2017 and 116.0 in 08/2017. The resident triggered for a significant weight loss at 90 and 180 days. The RD would trial and implement an 8-ounce vanilla mighty shake in place of milk during lunch. During an interview with the resident's family member on 06/27/18 at 09:04 AM, she stated the resident had extreme weight loss while at the facility. She stated if the resident was approached and asked if she wanted something she would often say no. If someone retrieved a snack, such as chocolate ice cream, and fed it to her then she would eat it. Dietetic technician #12 was no longer an employee of the facility at the time of the recertification survey. During an interview with certified nurse aide (CNA) #13 on 6/29/18 at 02:30 PM, she stated the resident was very confused, used to feed herself and now was not able to do so. She did not have any planned nourishment between meals and she would sometimes offer her an Ensure. She had weight loss and would benefit from between meal nourishments. During an interview with RD #11 on 07/02/18 at 01:23 PM, she stated the resident was followed monthly by nutrition staff. She stated it was the responsibility of a dietetic technician to monitor weights and notify the RD of any significant weight changes. She could not find any documentation that she was notified of the weight loss by the diet technician. She stated the dietetic technician had added super pudding in 11/2017. The resident had weighed 109 pounds in 12/2017 and in 01/2018 her weight went to 101 pounds. Interventions were not implemented until 02/12/18. She stated when she assessed the resident on 02/12/18, the resident had a significant loss at 90 and 180 days. She stated if she had known the resident had a significant loss in 01/2018 she would have implemented nutritional interventions at that time. 10NYCRR 415.12(i)(1)

Plan of Correction: ApprovedJuly 20, 2018

? #227 was not reassessed timely following a significant weight loss. This resident has received a monthly nutrition assessment, along with high calories interventions since 2/18.
. #227 care plan has been revised to include specific nutrition interventions, including but not limited to: super foods and high calorie beverages, along with continued weight and intake monitoring.
? Identifying others: The Dietetic technician and Registered Dietitian will meet at least monthly to review the weight records for all residents on assigned units. An audit of this meeting will be forwarded to the Director Clinical Nutrition each month, after the meeting is held.
? Measures put into place so as to provide timely nutrition assessment for weight loss will include education for Nutrition staff regarding timeliness of nutrition assessments.
.There were no changes to the current policy regarding Nutrition Assessment for weight loss, as the policy continues to be timely assessments upon discovery of weight loss.
. The audits include recording the meeting of the Registered Dietitian and Dietetic Technician weight reviews. The Dietetic technician and Registered Dietitian will meet at least monthly to review the weight records for all residents on assigned units. An audit of this meeting will be forwarded to the Director Clinical Nutrition each month, after the meeting is held.
The results of the audit will be reported at the facility Monthly QA/Risk Management Meeting
? Monthly reporting on the monthly weight meetings will be reviewed at Monthly QA Risk Management meetings and at the monthly Nutrition staff meetings. Audits will be performed for 3 consecutive months and then quarterly up to 12 months.
? Person responsible: Administrator.

FF11 483.10(c)(6)(8)(g)(12)(i)-(v):REQUEST/REFUSE/DSCNTNUE TRMNT;FORMLTE ADV DIR

REGULATION: §483.10(c)(6) The right to request, refuse, and/or discontinue treatment, to participate in or refuse to participate in experimental research, and to formulate an advance directive. §483.10(c)(8) Nothing in this paragraph should be construed as the right of the resident to receive the provision of medical treatment or medical services deemed medically unnecessary or inappropriate. §483.10(g)(12) The facility must comply with the requirements specified in 42 CFR part 489, subpart I (Advance Directives). (i) These requirements include provisions to inform and provide written information to all adult residents concerning the right to accept or refuse medical or surgical treatment and, at the resident's option, formulate an advance directive. (ii) This includes a written description of the facility's policies to implement advance directives and applicable State law. (iii) Facilities are permitted to contract with other entities to furnish this information but are still legally responsible for ensuring that the requirements of this section are met. (iv) If an adult individual is incapacitated at the time of admission and is unable to receive information or articulate whether or not he or she has executed an advance directive, the facility may give advance directive information to the individual's resident representative in accordance with State Law. (v) The facility is not relieved of its obligation to provide this information to the individual once he or she is able to receive such information. Follow-up procedures must be in place to provide the information to the individual directly at the appropriate time.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 2, 2018
Corrected date: August 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review, observation and interview during the recertification survey, the facility did not ensure advance directives were applied in a manner that was consistent with resident wishes for 1 of 3 residents (Resident #278) reviewed for advance directives. Specifically, Resident #278 was a DNR (do not resuscitate) and had another resident's (Resident #47) advance directive ID bracelet for CPR (cardiopulmonary resuscitation, full code) on his Broda chair (positioning geriatric chair) during multiple observations. Findings include: Resident #278 was admitted to the facility [DATE] and had [DIAGNOSES REDACTED]. The [DATE] Minimum Data Set (MDS) assessment documented the resident had severe cognitive impairment and required extensive assistance from staff for most activities of daily living (ADLs). The DNR/CPR Bracelets policy, revised [DATE] included: - Residents will wear a red identification (ID) bracelet to alert staff to CPR status: red=CPR. - Residents will wear a white ID bracelet to alert staff to DNR status: white=DNR. - When status has been determined the appropriate ID bracelet will be applied by the unit secretary or designee as determined by Nurse Manager (NM). - Staff will also apply appropriate color ID bracelet to wheelchair or equipment that physical therapy (PT) gives to the resident. The NM/Charge Nurse will assure ID bracelet of correct color is applied. The Medical Orders for Life-Sustaining Treatment (MOLST) dated [DATE] documented the resident's wishes were DNR, DNI (do not resuscitate/intubate), limited medical interventions, send to the hospital if necessary, no feeding tube, and determine use of antibiotics when infection occurs. The comprehensive care plan (CCP) updated [DATE] documented the resident's advance directives were DNR, he had a health care proxy (HCP) and his wishes related to advance directives would be understood and honored. The physician orders [REDACTED]. Resident #278 was observed with Resident #47's red ID bracelet (red=CPR) attached to his Broda chair: - On [DATE] at 12:10 PM in the dining room, and - On [DATE] at 8:47 AM in the dining room. Resident #47 was observed in bed on [DATE] at 11:00 AM and [DATE] at 9:00 AM wearing a red ID bracelet on his wrist. During an interview with certified nurse aide (CNA) #5 on [DATE] at 9:08 AM he stated he was assigned to Resident #278. He was not sure what his code status was but he would check the ID band. Red means DNR, white means full code. If the resident was unresponsive he would get the nurse as CNAs do not perform CPR at this facility. If the resident did not have an ID band on his wrist it might be on the wheelchair. During an interview with CNA #6 on [DATE] at 9:15 AM he stated the red ID bracelet means DNR and the white ID bracelet means full code. Sometimes ID bracelets were on the wheelchair. If a resident did not have an ID bracelet, the unit secretary was notified to make one and the nurse would then put it on the resident. During an interview with RN Manager #7 on [DATE] at 9:29 AM, she stated white ID bracelets mean DNR and red ID bracelets mean full code. Audits on ID bracelets were done every other week by the assistant director of nursing (ADON). If the ADON found a wrong or missing ID bracelet, she would tell the unit secretary. She stated the most recent audit for ID bracelets was [DATE], and provided the surveyor with a copy. The audit showed Resident #278 was a DNR and had white bracelets on his wrist and Broda chair, and Resident #47 was CPR and had red bracelets on his wrist and Broda chair. She stated Resident #278 went out for an appointment a few days ago and used a different wheelchair for van transport. When he returned from his appointment staff may have grabbed Resident #47's Broda chair instead of his. She stated her expectation was for CNAs to be looking at the ID bands and making sure they were the correct ones on the right resident. She stated staff were trained initially in orientation on advance directives/ID bands and re-educated as needed. 10NYCRR 415.3(e)

Plan of Correction: ApprovedJuly 20, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1) Resident?s #278 and #47 were placed in their correct chairs with the appropriate advance directive bracelets.
2) A full house audit will be conducted by the nurse manager?s on each unit to ensure residents are in appropriate chairs and to ensure ID bracelets correspond with the residents advance directives.
3) The DNR/CPR Bracelet policy was reviewed and staff will receive re-education to ensure the correct DNR/CPR bracelet is on the residents and that residents are placed in the correct wheelchair per the plan of care.
4) Audits will be completed monthly by the nurse manager on each unit to ensure to residents are in placed in the correct wheelchair and to ensure ID bracelets placed on the resident and their equipment correspond with the residents advance directives.
In addition, a monthly audit will be completed by the ADONs to question staff members across each unit to ensure they can verbalize the policy and procedure of CPR/DNR and coordinating bracelet colors.
5) These audit will be completed monthly on all nursing units for a minimum of three 3) months. The level of accepted compliance is 95%. The audit results will be presented at the Quality Assurance Meetings monthly to assure compliance is met and reoccurrence is prevented. The Quality Assurance committee will provide input on the need to continue, discontinue or modify the audits after the three (3) month period. The date for correction is [DATE]. The Director of Nursing is responsible to ensure continued compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

REGULATION: Electrical Equipment - Power Cords and Extension Cords Power strips in a patient care vicinity are only used for components of movable patient-care-related electrical equipment (PCREE) assembles that have been assembled by qualified personnel and meet the conditions of 10.2.3.6. Power strips in the patient care vicinity may not be used for non-PCREE (e.g., personal electronics), except in long-term care resident rooms that do not use PCREE. Power strips for PCREE meet UL 1363A or UL 60601-1. Power strips for non-PCREE in the patient care rooms (outside of vicinity) meet UL 1363. In non-patient care rooms, power strips meet other UL standards. All power strips are used with general precautions. Extension cords are not used as a substitute for fixed wiring of a structure. Extension cords used temporarily are removed immediately upon completion of the purpose for which it was installed and meets the conditions of 10.2.4. 10.2.3.6 (NFPA 99), 10.2.4 (NFPA 99), 400-8 (NFPA 70), 590.3(D) (NFPA 70), TIA 12-5

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 24, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not properly maintain electrical installations for 3 isolated areas (sixth floor chart room, first floor physical therapy office, and ninth floor television room near the fish tank). Specifically, multiple adaptors were plugged into each other (daisy chained) in the above referenced areas. Findings include: On 6/26/2018 at 2:20 PM, a surveyor in the sixth floor chart room observed there was a fan and pencil sharpener plugged into an approved 6 prong adaptor. This adaptor was plugged into another 6 prong adaptor, which was plugged into another 6 prong adaptor. On 6/27/2018 at 11:15 AM, a surveyor in the first floor physical therapy office observed there was a computer and phone plugged into an approved 6 prong adaptor. This adaptor was plugged into an unapproved extension cord, which was plugged into another unapproved extension cord. On 6/26/2018 at 12:15 PM, a surveyor in the 9th floor lounge observed there was a fish aquarium was plugged into an unapproved 6 prong adaptor. In addition, the aquarium lighting was plugged in series with a light timer, which was plugged into the unapproved 6 prong adaptor. During an interview on 6/26/2018 at 12:15 PM, the Corporate Director of Operations stated all the fish tanks are taken care of by an outside vendor and he would need to educate them on the use of electrical adaptors. During an interview on 6/29/2018 at 11:28 AM, the Director of Facilities stated he was not aware of the daisy chained adaptors identified during survey. The staff were trained during orientation and annual inservice that this was not allowed, and electrical adaptor signage was posted throughout the facility. 2012 NFPA 99: 10.2.4 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJuly 20, 2018

The identified electrical issues were all corrected on (MONTH) 27TH, (YEAR) by the in-house electrician. A full house assessment will be completed by (MONTH) 15, (YEAR) and any identified extension cords and multiple plug adaptors will be removed. This will be completed by the in-house electrician.
A full house training and communication will be completed by (MONTH) 24, (YEAR) to include all staff on our electrical compliance standards. This will also be discussed with elders at the next scheduled full house resident council and a mailer was sent out to families in the July. Signage currently exist on all units to communicate the electrical policy. The TV?s stationed in common areas will also provide added communication about electrical safety in the Facility, these are located in the employee café and lobby area at entrance of both buildings, and this will be completed by (MONTH) 24th, (YEAR).
In addition, the in-house electrician will perform facility wide monthly audits as well to inspect all areas for compliance. In addition, the facilities manager will perform an audit monthly on all office space/common areas to look for extensions that are non- compliant. The tagging system on all electrical will be utilized to control compliance facility wide.

A letter of communication along with our policy will be sent to all vendors with information on required code compliance for electrical cords and extensions in use. This will be completed by (MONTH) 24, (YEAR).
The Director of Facilities will be responsible for compliance.
The results of audits will be reported to the Quality Assurance team for the next 6-months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.

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: June 29, 2018
Corrected date: August 24, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 2 isolated rooms (rear auditorium stairwell and loading dock) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 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 fan room/record storage room contained both quick response and standard response sprinkler heads. Findings include: On 6/26/2018 at 4:45 PM, a surveyor observed the rear auditorium stairwell contained 1 quick response sprinkler head and 1 standard response sprinkler head. On 6/27/2018 at 9:44 AM, a surveyor observed the loading dock contained 1 quick response sprinkler head and 7 standard response sprinkler heads. During an interview with the Director of Facilities on 6/29/2018 at 11:20 AM he stated he was not aware that mixed sprinkler heads were an issue according to code. 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: ApprovedJuly 20, 2018

The identified sprinkler heads will all be corrected by (MONTH) 24th, (YEAR) by ABJ Fire Protection.
A meeting was held with the ABJ executive team on (MONTH) 2, to review the issues identified during the survey. The correct sprinkler heads will be installed by (MONTH) 24th, (YEAR) and all sprinkler heads will not be mixed going forward and compliance will be audited by the Director of Facilities monthly for the next 6- months .
A full house inspection of all sprinklers will be completed by the vendor on (MONTH) 24th th to correct any widespread issues found. This will include checking for the proper sprinkler heads types and that all escutcheons are in place properly mounted.
In addition, the Director of Facilities will provide the maintenance staff education and training on Sprinkler Head compliance. This will be completed by (MONTH) 24, (YEAR).
The Director of Facilities will conduct a monthly audit for the next six months to check for proper installation of the sprinkler heads and review documentation from the vendor for compliance.
The Director of Facilities will be responsible for overall compliance.
The results of audits will be reported to the Quality Assurance team for the next 6-months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.

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: June 29, 2018
Corrected date: August 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 for seven isolated areas (second floor freezer #1, second floor freezer #2, basement trayline freezer, second floor C2 cooler, fifth floor dining room storage closet, fourth floor dining room, and second floor employee break room). Specifically, the second floor freezer #1, the second floor freezer #2, the basement trayline freezer, and the second floor C2 cooler all had damaged sprinkler heads; the basement trayline freezer, the fifth floor dining room storage closet, the fourth floor dining room, and the second floor employee break room contained sprinkler heads that lacked escutcheon covers; and the Cunningham Building sprinkler system lacked a hydraulic nameplate. Findings include: 1) Damaged Sprinkler Heads On 6/26/2018 at 9:35 AM, a surveyor observed that in the second floor freezer #1 and the second floor freezer #2 there were sprinkler heads that did not visually have temperature fluid in the frangible glass bulbs. There were icicles formed around and on the sprinkler head. On 6/26/2018 at 9:50 AM, a surveyor in the basement trayline freezer observed one sprinkler head did not visually have temperature fluid in the frangible glass bulbs. On 6/27/2018, between 3:02 PM and 3:12 PM, a surveyor in the second floor C2 cooler observed a sprinkler head with green fluid leaking from it. This sprinkler head was rated for 175 Fahrenheit, and the color of the liquid inside the bulb was a light green. During an interview on 6/29/2018 at 11:20 AM, the Director of Facilities stated he was not aware of the freezer sprinkler heads that lacked temperature fluid. If there were any issues with sprinkler heads he thought the sprinkler vendor would identify and correct them. 2) Missing Escutcheons On 6/26/2018 at 9:50 AM, a surveyor in the basement trayline freezer observed a sprinkler head without an escutcheon plate. On 6/26/2018 at 2:50 PM, a surveyor in the fifth floor dining room storage closet observed a sprinkler head without an escutcheon plate. On 6/27/2018 at 12:00 PM, a surveyor in the fourth floor dining room observed a sprinkler head without an escutcheon plate. On 6/27/2018 at 2:48 PM, a surveyor in the second floor employee break room observed a sprinkler head without an escutcheon plate. During an interview on 6/29/2018 at 11:20 AM, the Director of Facilities stated he was not aware of the missing sprinkler escutcheons identified during survey. 3) Missing Hydraulic Name Plates On 6/27/2018 at 11:20 AM, a surveyor in the Cunningham Building mechanical room observed that the sprinkler system lacked a hydraulic name plate. During an interview on 6/29/2018 at 11:20 AM, the Director of Facilities stated he was not aware the hydraulic name plate for the Cunningham Building sprinkler system was missing, or why the third party sprinkler vendor checked not applicable on the quarterly sprinkler reports. During review on 6/27/2018 of the Cunningham Building quarterly sprinkler inspection reports, revealed the third quarter of (YEAR), the fourth quarter of (YEAR), the first quarter of (YEAR), and the second quarter of (YEAR) all referenced that hydraulic plaques were not applicable. 2012 NFPA 101: 19.3.5.1, 9.7.5 2011 NFPA 25 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJuly 20, 2018

The missing name plate on the fire pump that was in the process of being replaced during the survey to the new fire pump will be fully compliant by (MONTH) 26th. The identified escutcheons will be repaired or replaced by (MONTH) 24th (YEAR) along with any damaged sprinkler heads.
A meeting was held with the vendor (ABJ) on (MONTH) 2, (YEAR) to discuss the documentation issues identified on the reports provided to the facility. Expectations for reports going forward were reviewed and will not reflect N/A for code required compliance items. The Director of Facilities will review and audit monthly all reports going forward.
A full house inspection of all sprinklers will be completed by the vendor on (MONTH) 24th to correct any issues found. This will include checking for the proper sprinkler heads types, damaged sprinkler heads and that all escutcheons are in place properly mounted.
In addition, the Director of Facilities will provide the maintenance staff education and training on Sprinkler Head compliance. This will be completed by (MONTH) 24, (YEAR).
The Director of Facilities will do monthly audits to make sure the reports are correct from the vendor and a visual inspection for compliance on the sprinkler heads , escutcheons , name plate on the hydraulic plate are in place. This will be completed for the next 4- months.
The Director of Facilities will be responsible for compliance.
The results of audits will be reported to the Quality Assurance team for the next 6-months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds.

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

REGULATION: Vertical Openings - Enclosure 2012 EXISTING Stairways, elevator shafts, light and ventilation shafts, chutes, and other vertical openings between floors are enclosed with construction having a fire resistance rating of at least 1 hour. An atrium may be used in accordance with 8.6. 19.3.1.1 through 19.3.1.6 If all vertical openings are properly enclosed with construction providing at least a 2-hour fire resistance rating, also check this box.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 29, 2018
Corrected date: August 24, 2018

Citation Details

Based on observation and interview conducted during the Life Safety Code survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 6 of 13 floors (twelfth floor rethermal storage room, eighth floor northwest electrical closet, fourth floor northwest electrical closet, third floor northwest electrical closet, second floor northwest electrical closet, second floor fire alarm control room, and first floor). Specifically, these areas had unsealed vertical penetrations. Findings Include: On 6/26/2018 at 11:16 AM, a surveyor in the twelfth floor rethermal storage room observed there were two unsealed hot water pipes passing into the floor below. On 6/26/2018 at 12:34 PM, a surveyor in the eighth floor northwest electrical closet observed unsealed cable television lines passing into the floor below. During an interview on 6/26/2018 at 12:34 PM, the Director of Facilities stated the cable company was in the facility approximately two months ago and installed cable lines. On 6/26/2018, between 3:50 PM and 4:14 PM, a surveyor in the third floor northwest electrical closet observed an unsealed fire alarm wire passing into the floor below, and into the ceiling above. The surveyor confirmed the second floor northwest electrical closet ceiling and the fourth floor northwest electrical room floor did have unsealed penetrations from the fire alarm wire. On 6/26/2018 at 4:21 PM, a surveyor in the second floor fire alarm control room observed the inside of a three inch conduit was passing into the first floor below and was not sealed. There was a bundle of cables passing through this conduit. During an interview on 6/26/2018 at 4:21 PM, the Director of Facilities stated wires were being installed within this conduit since late 4/2018. During an interview on 6/29/2018 at 11:32 AM, the Director of Facilities stated he was not aware of the unsealed vertical penetrations identified in the twelfth floor rethermal storage room, and the second through fourth floor northwest electrical closets. 2012 NFPA 101: 19.3.1, 8.6.2 10NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJuly 20, 2018

The identified vertical penetrations will corrected by (MONTH) 24th, (YEAR).
A full building assessment of all electrical closets will be completed by (MONTH) 24, (YEAR). This audit will be completed by the Director of Facilities.
A letter of communication will be sent to all Vendors with our policy on penetration and the installation of wires and cables by (MONTH) 15th, (YEAR).
A fire penetration agreement document will be utilized for vendors performing work that may result in penetrations. This document will be utilized by the Facility Director to inspect and check all work done to compliance.
In addition to making the corrections and repairs, Training and education will be provided to all maintenance staff on NFPA 101- vertical penetrations /openings ?and compliance. This will be completed by (MONTH) 24, (YEAR)
The results of audits will be reported to the Quality Assurance team for the next 6-months. The Quality Assurance team will then provide input on the need to continue or discontinue reporting to this committee based on compliance thresholds. The Director of Facilities will be responsible for all compliance and corrections.