NYS Veterans Home in NYC
September 23, 2016 Certification Survey

Standard Health Citations

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

Based on observation, and staff interview the facility did not ensure that food was stored under sanitary conditions to prevent food borne illness. Specifically, expired food items were observed stored in the refrigerator. This was evident during observations conducted during the Kitchen Tour. The findings are : During the initial Kitchen Tour conducted with the Food Service Director (FSD) on 9/19/16 at 7:15 am. The following was observed: 1. A metal pan of puree fruit dated expired on 9/16/16 in the cold food prep refrigerator 2. A metal pan of sliced turkey dated 9/14-9/17/16 in the cold food prep refrigerator 3. A metal pan of muffins dated 9/10/16 to 9/14/16 in the cold food prep refrigerator 4. A metal pan of applesauce not dated in the cold food prep refrigerator 5. A metal pan of pureed fruit dated 9/10/16 to 9/15/16 in the cold food prep refrigerator 6. A metal pan of coleslaw dated 9/15/16-9/17/16 in the cold food prep refrigerator 7. A spice of Coriander seeds dated on 2/11/11 was observed in the store room. 8. In the Dairy/ Produce refrigerator two food items in separate pans were not dated; Sausage and muffins. An interview was conducted with the FSD immediately after the observations. The FSD stated that the Food service Manager is responsible for checking the prep refrigerator and the food items are kept in the refrigerator for three days. He further stated that the Chef is responsible for ordering and discarding spices. The chef was immediately interviewed and stated that the spices can be held for a year and added that this item is expired. The Policy on Food Supply Storage Procedures date 1/16 documents: All food, non food items and supplies used in food preparation shall be stored in such a manner as to prevent contamination to maintain the safety and wholesomeness of the food for human consumption. Procedures: Cover, label and date unused portions and open packages. Refrigerated Storage: Discard food past the use by or expiration date. 415.14(h)

Plan of Correction: ApprovedNovember 29, 2016

F371
I. Corrective Actions for Affected Area
All items identified in the Survey Report were discarded immediately by the Director of Dining Services. The Facility respectfully states that no residents were served the expired items identified in the Statement of Deficiency.

II. Identification of Other Areas Potentially
Affected
All refrigerators identified and other areas where food is stored, including refrigerator items and canned items, were checked to ensure that all expired items were discarded.

III. System Changes and Measures to Prevent
Reoccurrence
1. The Facility?s Policy and Procedure on ?Production, Purchasing and Storage,? was reviewed and revised to include responsible employee who will check all refrigerators, walk-in, storerooms, pantries and resident Dining Room refrigerators. Staff were in-serviced on the changes to the Policy.
2. Dining Services Supervisor/Manager on the evening shift has been assigned the responsibility to discard expired items. Dining Services Manager will audit refrigerators at 3:00 PM and 7:45 PM daily to ensure no expired items are present.
3. All refrigerators in the Kitchen will be locked after the Dinner meal check, to ensure items are not placed in the refrigerators after they have been checked for the closing of the Kitchen.

IV. Monitoring of Corrective Action
The Director of Dining Services updated the Audit Tool to include checking refrigerators for expired items. Audit Tool will be used by the Clinical Nutrition Manager and the Director of Dining Services to audit refrigerators. Any items out of compliance will have on the spot corrective action.

V. QA Monitoring
Findings will be presented by the Director of Dining Services/Designee to the CQAI Committee monthly for six (6) months and then quarterly thereafter for twelve (12) months.

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) The facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, the facility did not ensure that infection control practices were maintained. Specifically, a residents oxygen tubing was observed on the floor. This was evident for 1 of 29 resident observations during Stage 2 (Resident #75). The finding is: Resident #75 is a [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had severely impaired cognition.The MDS further documented the resident received oxygen therapy. On 9/20/16 at 9:54 AM, 10:35 AM, and 1:00 PM the resident was observed in bed with oxygen in use. The oxygen tubing was on the floor. On 9/21/16 at 12:59 PM, the resident's oxygen tubing was observed on the floor mat. On 9/23/16 at 11:08 AM, the resident was observed in bed with oxygen in use. The tubing was on the floor underneath the corner of the floor mat. On 9/23/16 at 11:15 AM, the Licensed Practical Nurse (LPN) was interviewed and stated that the oxygen tubing is changed weekly by the night nurse and checked every shift by the nurses. She further stated that she checks the tubing and changes it as needed if it is dirty. The LPN stated the oxygen tubing should be kept off the floor. On 9/23/16 at 11:26 AM, the Registered Nurse (RN) was interviewed and stated oxygen tubing should not be on the floor, and all staff are aware of that. She further stated that perhaps because the resident has a low bed, the oxygen tubing gets on the floor, but the staff could loop it to keep it off the floor. 415.19(a)(1-3)

Plan of Correction: ApprovedNovember 29, 2016

F441
I. Corrective Actions for Affected Residents
1. Resident #75 who was affected by this deficient practice received a new oxygen tubing immediately. The Facility respectfully states that there was no negative outcome to the resident.
2. RNs, LPNs and CNAs caring for resident # 75 received Educational Counseling, emphasizing that the proper placement of the oxygen tubing is checked during care, and is in compliance with infection control procedures.

II. Identification of Residents Potentially Affected
1. All other residents on oxygen had tubing checked to ensure that they were secured in a manner that was in compliance with the Infection Control Policy.
2. Infection Control Rounds were conducted on all Residential Units by the Director of Nursing and the Associate Directors of Nursing on the evening of 9/23/16. No infection control violations were observed.

III. System Changes and Measures to Prevent
Reoccurence
1. Infection Control Policy and Procedure pertaining to respiratory tubing was reviewed and revised.
2. The Staff Educator and the Infection Control Nurse will rein-service all Licensed Nurses on the Infection Control Policy revisions regarding respiratory tubing, to ensure that oxygen tubing are never in contact with the floor or any other contaminated surfaces. Sign-In Sheets will be filed for reference and validation.
Lesson Plan will include but is not limited to:
a. Certified Nursing Assistants are reminded that during hourly rounds, residents who have oxygen tubing must be checked to ensure it is still properly secured to avoid infection control violation. If oxygen tubing is observed in contact with a contaminated surface, the Licensed Nurse will be informed immediately.
b. Licensed Nurses will observe for properly secured placement of oxygen tubing during Unit Rounds, Treatment Care, Medication Pass and as needed, ensuring compliance with Infection Control Policy.
c. When oxygen tubing is observed on any contaminated surface, it would be removed and replaced immediately by the Licensed Nurse.
d. All Oxygen tubing will be secured in a clear plastic bag to prevent contact with contaminated surfaces when not in use.

IV. Monitoring of Corrective Action
1. The Director of Nursing developed an Audit Tool to monitor Infection Control concerns on each Unit. The Tool will be used by the Nursing Supervisors to monitor Infection Control compliance of oxygen tubing placement, as well as other relevant Infection Control areas.
2. Unit Managers will conduct daily Infection Control Rounds on each Unit. Nursing Supervisors will conduct Weekly Environmental Rounds on their Units to ensure that oxygen tubing are properly secured on the residents when in use, and when not in use, stored in a clear plastic bag. Any negative findings will warrant on the spot Corrective Action and documentation on the Audit Tool. Audit Tools will be given to the Director of Nursing/Designee for follow-up and report.

V. QA Monitoring
Findings will be presented by the Director of Nursing/Designee to the CQAI Committee monthly for six (6) months and quarterly thereafter for twelve (12) months.

FF09 483.25(g)(2):NG TREATMENT/SERVICES - RESTORE EATING SKILLS

REGULATION: Based on the comprehensive assessment of a resident, the facility must ensure that -- (1) A resident who has been able to eat enough alone or with assistance is not fed by naso gastric tube unless the resident ' s clinical condition demonstrates that use of a naso gastric tube was unavoidable; and (2) A resident who is fed by a naso-gastric or gastrostomy tube receives the appropriate treatment and services to prevent aspiration pneumonia, diarrhea, vomiting, dehydration, metabolic abnormalities, and nasal-pharyngeal ulcers and to restore, if possible, normal eating skills.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and interview the facility did not ensure that a resident who is fed by a gastrostomy tube receives the appropriate treatment and services to prevent complications. Specifically, during a Medication Administration Observation, the unit LPN ( Licensed Practical Nurse) did not check the placement of the resident's gastrostomy tube prior to administering medication and fluids. The findings are: Resident #175 is a [AGE] year old re-admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. On 9/23/16 at 9:42 am, during a Medication Administration Observation, the LPN was observed exposing the residents gastric tube prior to the administration of medication. The LPN connected an irrigation syringe to the gastric tube and administered approximately 10 cc (centimeters) of water. She continued to administer the ordered medication and flushed the tube with 30 cc of water. The Admission Minimum Data Set ((MDS) dated [DATE] documented: intact cognition, extensive assistance with bed mobility and total dependence for eating. The MDS further documents feeding tube. The Physician order [REDACTED]. LPS 15/30 Liquid 30 ml Via gastric tube 1 time a day. The CCP (Comprehensive Care Plan) dated 9/10/2016 documented: Potential for aspiration related to tube feeding. Patients with nasogastric (NG) or gastrostomy tubes-check placement before feeding. Check residuals before feeding. Hold feeding if residuals are high and notify the physician. Position head of bed An interview was conducted immediately with the LPN who stated that before any medication or fluid is administered via the gastric tube, she should check for placement. She stated that placement is checked by attaching an irrigation syringe, and checking the amount of aspirated stomach contents or by using a stethoscope and inserting 30 cc of air into the tube and listening for a swish sound over the stomach. The LPN then added that she had forgotten to do so during the observation. During the observation, the LPN was not observed in possession of a stethoscope. The policy titled Medication Administration General dated 9/2007 documents: Before administering any medication via an enteral feeding tube it is important to: Check the enteral feeding tube by injecting 30 cc of air into tube from syringe while auscultating the residents stomach with a stethoscope. Listen for the whooshing sound of air entering the stomach to indicate proper placement. 483.25(g)(1)

Plan of Correction: ApprovedNovember 29, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F322
I. Corrective Actions for Affected Residents
1. Resident #175 had no negative adverse effects observed from the Nurse not checking placement of Gastrostomy Tube during medication administration. Resident continues to remain stable as of this Plan of Correction.
2. LPN has been re-educated by the Staff Educator on the Facility?s Medication Administration Policy that mandates to check gastrostomy tube for placement prior to medication administration or feedings. The LPN was reminded that her stethoscope must be in her possession when on duty.

II. Identification of Residents Potentially Affected
1. The Director of Nursing/Designee compiled a list to identify all residents with Enteral tubes. All Nurses assigned to residents with Enteral Tubes were prioritized to receive In-service Training and Competencies on managing residents with Enteral Tubes. Medication administration competency forms will be revised to indicate the presence of a stethoscope as part of Med-pass.

III. System Changes and Measures to Prevent
Reoccurence
1. The Facility?s Policy and Procedure on Medication Administration specific to Enteral Tube Feeding, was reviewed and found to be compliant. All Nurses will be rein-serviced on this policy by the Staff Educator. Sign-In Sheets will be filed for reference and validation.
Lesson Plan will include but not be limited to:
a. Properly position the resident in the Semi-Fowler position.
b. Wash hands and don gloves.
c. Close any ports on the Enteral Tube to ensure there is an airtight seal.
d. Check the Enteral feeding tube by injecting 30cc of air into tube from syringe while auscultating the resident?s stomach with a stethoscope. Listen for the ?whooshing? sound of air entering the stomach to indicate proper placement, or aspiration of gastric contents.
e. Flush tube with at least 30cc of water before administration of medications.
f. Prepare each medication separately.
g. If more than one (1) medication is to be administered, flush between medications with at least 10cc of water to ensure that each medication is cleared from the tube.
h. Flush tube with at least 30cc of water following administration of last medication.

IV. Monitoring of Corrective Action
1. The Director of Nursing developed an Audit Tool to monitor residents on Enteral Tubes. The Audit Tool will be used to ensure Nurses are [MEDICATION NAME] proper procedure when administering Enteral tube medication or feeding, and they are in possession of the required tools during medication administration, and are using it appropriately as per the physician orders.
2. Nursing Supervisors will monitor Licensed Nurses for competencies during medication administration. Any negative findings will warrant on the spot corrective action and documentation on the Audit Tool. Results on the Audit Tool will be communicated to the Director of Nursing/Designee for follow-up.

V. QA Monitoring
Findings will be presented by the Director of Nursing/Designee to the CQAI Committee monthly for six (6) months and quarterly thereafter for twelve (12) months.

FF09 483.75(o)(1):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

Based on observation and interview, the facility did not ensure that the Quality Assessment and Assurance committee developed and implemented appropriate action plans for identified quality concerns. Specifically, the QA&A (Quality Assessment and Assurance) committee did not develop appropriate action plans to address previously identified concerns with the resident dining and meal service. The finding is: Refer to citation text F 362 for Sufficient Dietary Staff On 9/23/16 at 3:38:19 PM, the Administrator was interviewed and stated that the QA&A committee identified a concern with the meal service times and had been looking at it for a while. He stated that multiple causes were identified related to the meal service which included the dietary staff getting the food to the units on time and the nursing staff reporting to the dining rooms in a timely manner. He stated that they developed a system to ring a bell when the dietary staff was ready as a reminder for the nursing staff to report to the dining room. In addition, the Dietary Supervisors were responsible for monitoring to ensure that the food is getting to the units on time. The Administrator further stated that there had not been an appreciable improvement, but there was no consistent reason that had been identified as to why the meals are late. He stated it is hard to fix the human component in regard to staff calling out, trays falling over, etc. The Administrator stated that the project for meal service started long ago, but it was stopped due to an issue with the meal temperatures of room trays, which became the priority. He stated that breakfast is probably the latest meal, but meals usually start 15 to 20 minutes late. The survey team did not observe any reminder bells being used during the meal observations. 415.27(a-c)

Plan of Correction: ApprovedNovember 29, 2016

F520
I. Corrective Actions for Affected Area
1. The Facility respectfully states that a Continuous Quality and Assurance Initiative (CQAI) for Meal Services and Dining Room Observation were actively in process with the QA Committee at the time of this Survey.
2. The on-going QA process for meal times was one of the focus areas of the MEAL SERVICE PROGRAM. The sections of this program include the following:
a. Dining Services Preparation Pre-meal (Food Trucks, Beverage Carts, Temperatures).
b. Process During Meals (plate meals, replenish beverages, prepare alternates).
c. Nursing Process Pre-meal (sort meal tickets, resident preferences)
d. Nursing Process During Meals (serve beverages, serve trays, assist feeders).
e. Temperature and Tray Accuracy of Meals.
f. The Delivery Times of Meals to Residents (both in the Dining Rooms and in resident rooms).
g. Post Meal Process (Meal Accountability).

II. Identification of Other Areas Potentially
Affected

All Dining Rooms are included in the assessment and corrective action process for the meal service. The 2nd and 3rd Floor Dining Rooms are identical for meals set-up while the 1st and 4th Floor Dining Rooms are different in set-up.
1. The 1st Floor is served in two spaces from one steam table. The residents that are in the Lounge space are served as one group, and the residents in the Main Dining Room space are served as another group, for a total of 35 residents.
2. The 2nd floor residents are served from one steam table in the Main Dining Room for a total of 80 residents.
3. The 3rd floor residents are served from one steam table in the Main Dining Room for a total of 80 residents.
4. The 4th Floor residents are served in two spaces from one steam table. The residents that are on the Poplar space are served together as one group, and the residents in the Main Dining Room space are served as another group, for a total of 55 residents.
5. All areas are monitored for QA performance based upon each floor?s established process for meal service.

III. System Changes and Measures to Prevent
Reoccurrence
1. The Facility?s Policies and Procedures on the CQAI, ?The Country Kitchen and Meal Service Process, were reviewed and found to be in compliance. All staff serving meals in the Dining Rooms will be rein-serviced on the Policies and Procedures. Sign-in sheets will be filed for reference and validation.
2. Facility will conduct a CQAI review of the Meal Service Process to ensure that meals are delivered to the Units in a timely manner and that the meal service starts on time. Any changes after review will be implemented to meet goals.
3. The Facility will accelerate the CQAI process of identifying deficient practices during meal service and present a baseline conclusion in 30 days.
4. The Administrator met with the Director of Dining Services and the Director of Nursing to review individual department's CQAI response to the findings.
5. Facility will schedule weekly meetings with the Management Team for CQAI purposes, until compliance is met. If at the end of the complete review it is deemed that additional staff is needed, it will be addressed.

IV. Monitoring of Corrective Action
1. The Director of Dining Services and the Director of Nursing reviewed the CQAI Audit Tool for Dining Room Rounds. Audits will be done daily to ensure that meals begin on time. Negative findings will warrant an investigation of the reason why the meals were not on time. These findings will generate a CQAI Report.
2. Nursing Supervisors/Designee and Dining Services Supervisors/Designee will be available for at least 10 minutes leading up to the start of meals to ensure Dining Room supervision of the meal service. The Audit Tool will be used to record any negative findings. Audits will be shared with the Director of Dining Services and the Director of Nursing for follow-up.

V. QA Monitoring
Findings will be presented by the Director of Dining Services/Designee and the Director of Nursing/Designee, to the CQAI Committee monthly for six (6) months then quarterly thereafter for twelve (12) months.

FF09 483.10(g)(1):RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE

REGULATION: A resident has the right to examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility. The facility must make the results available for examination and must post in a place readily accessible to residents and must post a notice of their availability.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

Based on observation and interveiw, the facility did not ensure that the survey results were readily accessible to residents and visitors. The findings are: On 9/20/16 at 4:00 PM and 9/21/16 at 4:44 PM, the binder that holds the survey results, located in the facility's lobby was reviewed. The binder did not contain the survey results from the previous recertification survey. The binder contained the post-survey revisit letter and report for the previous recertification survey. On 9/19/16 at 11:06 AM the Resident Council President was interviewed and stated that the survey results are kept in a binder located in the lobby by security. On 9/21/16 at 4:41 PM, the Administrator was interviewed and stated that the Social Worker is responsible for posting the survey results for the residents. On 9/21/16 at 4:44 PM, the Director of Social Work was interviewed and stated that she puts the survey results in the binder as soon as the report is received by the facility. She further stated that she did not know why the results were not there, but it is possible someone removed them from the binder. 415.3(1)(c)(1)(v)

Plan of Correction: ApprovedNovember 29, 2016

F167

I. Corrective Actions for Affected Area
The Director of Social Work immediately ensured that the Facility?s DOH Survey results for (YEAR), was in the DOH Survey Results binder. The binder is located in the Lobby on the first floor, across from the Security desk.
II. Identification of Other Areas Potentially
Affected
There are no other areas in the Facility where DOH Survey Results binder is kept.
III. System Changes and Measures to Prevent
Reoccurrence

1. A Policy and Procedure on ?Right to Survey Results,? was developed by the Director of Social Work. All Social Work staff will be in-serviced on the Policy and Procedure.
2. The Director of Social Work/Designee attended the Resident Council meeting scheduled on (MONTH) 6, (YEAR) and presented reminder regarding the location of DOH most recent Survey results. The Director of Social Work/Designee will ensure posting of information regarding the location of the DOH Survey Results binder.
3. The Director of Social Work/Designee will review on Mondays, Wednesdays and Fridays, the DOH Survey Results binder for availability and accessibility of documents.
4. The Director of Social Work developed a Log Book to document review of the presence of DOH Survey results in binder. Social Workers will be in-serviced on this process. The Log Book will be used for audits.

IV. Monitoring of Corrective Action
The Director of Social Work developed an Audit Tool for monitoring access of DOH Survey results by residents and visitors. The Tool will be completed by the Director of Social Work/Designee 3 times per week, on Mondays, Wednesdays and Fridays. The DOH Survey Results binder will contain:
i. The Cover Letter
ii. The SOD
iii. The P(NAME)
iv. The P(NAME) Acceptance Letter

V. QA Monitoring
Findings will be presented by the Director of Social Work/Designee to the CQAI Committee monthly for six (6) months and then quarterly thereafter for twelve (12) months.

FF09 483.35(b):SUFFICIENT DIETARY SUPPORT PERSONNEL

REGULATION: The facility must employ sufficient support personnel competent to carry out the functions of the dietary service.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 16, 2016

Citation Details

Based on observation and interview, the facility did not ensure that sufficient support staff were provided to carry out the functions of the dietary service. Specifically, during dining observations that were conducted for breakfast and lunch, meals were not served to residents within the scheduled timeframe's. This was evident during meal Dining Observations for 3 of 5 resident units. (Units 1, 2 and 4-Maple). The findings are: 1) On 9/19/16 at 8:00 AM the 4th floor (Maple) dining service was observed during breakfast. The observed posted time for breakfast was 8:00 AM. During the observation, the food was on the unit at this time. The Dietary staff did not start preparing the trays for service to the residents in the dining room until 8:30 AM. During the delay, there was a nurse observed in the dining room, sorting through the meal tickets after 8:00 AM in preparation for the meal service. 2) On 9/19/16 breakfast was observed on the first floor unit ( Pine). At 8:00 am, the residents were sitting in the dining room waiting for breakfast to be served. An RN (Registered Nurse) was also present. The CNA was observed serving juice and water to the residents at 8:20 AM. At approximately 8:35 AM, the staff began serving the residents food. 3) On 9/20/16 at 1:14 PM, Resident #225 was interviewed and stated he believed the meals could be served faster. He stated that residents often has to wait one half hour before the food trays are prepared and his meal is served. He further stated that the residents are just sitting in the dining room hungry and waiting. 4) On 9/21/16 from 11:54 AM to 1:11 PM, the 2nd Floor lunch service was observed. The posted lunch time was 12:15 PM. The staff offered hand wipes to residents at 12:02 PM, and food temperatures were taken at 12:17 PM. The meal service began at 12:32 PM. There were ten CNA's (Certified Nurse Assistants) assisting three FSWs (Food Service Workers) preparing plates. At 12:52 PM, there were residents that had not been served. Prepared food trays were placed on a cart for room service at 12:58 PM. At 1:09 PM, a resident who was waiting for his lunch on the Beech unit came out of his room, wheeled himself to the dining room and complained to staff about the delay in receiving his meal. At 1:11 PM, a CNA was observed entering the unit with a cart of food trays to dispense to the residents who were eating lunch in their rooms. On 9/19/16, at approximately 8:25 AM, the Dietary Aide was interviewed and stated that breakfast should be served at 8:00 AM, but before the meal service, she is responsible for taking the food temperatures, reviewing the production sheets, and ensuring that all the required items are there. She further stated that the meal tickets are also reviewed. Once all of these tasks are completed, she starts preparing the trays, and the CNAs can then serve the residents. On 9/23/16 at 2:45 PM, the Food Service Worker was interviewed and stated that she works as both a food server and a food helper. She stated that the food servers prepare the plates at the steam table, and the food helper takes the temperatures and obtains items from the kitchen. She stated that there are usually two people serving breakfast and lunch on all units except Pine and Maple/Poplar (1st and 4th floor), where there is only one server assigned. She further stated that meal service should begin at the posted times with the last tray served for breakfast by 9:00 AM and lunch at 1:15 PM. At times there are delays in meal service when the nursing staff does not sort the meal tickets or when the meal truck is late. The FSW further stated that the meal tickets should be sorted 15 minutes the before each meal service. On 9/23/16 at 2:53 PM, another FSW was interviewed and stated that today, he covered the 4th floor as a server for breakfast and lunch. He stated that breakfast in the Poplar unit starts at 7:50 AM, and he started preparing trays at 8:00 AM. The FSW stated that he began serving the residents in Maple (the larger room) at 8:15 AM and that it was the first time he had to serve the two dining rooms. On 9/23/16 at 2:59 PM, a 2nd floor Certified Nursing Assistant was interviewed and stated that meal tickets should be sorted by the nurses or the CNAs at 7:45 AM for breakfast and 11:45 AM for lunch. She further stated that the plates are served to the residents as they become available from the server. She stated that sometimes there are complaints about the wait times for the meal service, and residents have waited up to an hour for their food. The CNA stated that the meal service delay depends on who serves the food because some servers are faster than others. She also stated that the Food Service Supervisor and Dieticians observe the meals and are aware of the delays. On 9/23/16 at 3:04 PM, a FSW was interviewed and stated that the meal service should begin at the posted times, but the nurses have to give the servers the meal tickets first. She further stated sometimes the meal tickets are not given on time, resulting in a delay, this issue happens often. She stated that all meals should be served, for the dining room and resident rooms, within 45 minutes to 1 hour. Most of the time breakfast is served by 9:00 AM and lunch by 1:00 PM. On 9/23/16 at 3:08:52 PM, the CNA assigned to the 2nd floor, was interviewed and stated breakfast should start at 8:00 AM, but sometimes the dietary staff are not ready or the nurse is not available. The CNA stated that residents complain about the wait time for meals. She stated that meals are served by table, and they rotate who is served first. She further stated that some residents wait up to 30 minutes or a little more for their meals. On 9/23/16 at 3:18 PM, the Food Service Director (FSD) was interviewed and stated that the breakfast service is between 8:00 AM and 9:00 AM, and lunch service is between 12:15 PM and 1:15 PM. She stated there are some residents that have complained about the wait time for service, so the staff alternates which side of the dining room is served first. The FSD further stated the nurse sorts the tickets according to which residents are in the dining room. In addition, as residents come in, the nurse asks for that residents tray if the resident is seated at a table where other residents are already eating. When residents complain about the wait, the nursing staff will go get the tray to accommodate them. The FSD stated there have been delays in the start of meal service related to the nursing staff coming to the dining room to sort the tickets. When this happens, the dietary staff attempts to find out which nurse is assigned to the dining room so the meal can begin. The facility policy and procedure for Meal Service Time reviewed 5/15 documented the meal service hours are as follows: Breakfast 8:00 AM, Lunch 12:15 Noon, and Dinner 5:15 PM. The policy further documented Meal service commences at these times and the first tray is served approximately 5 minutes later. 415.14(b)(1)(2)

Plan of Correction: ApprovedNovember 29, 2016

F362
I. Corrective Actions for Affected Area
Dining Services staff who was assigned to the 1st, 2nd and 4th Floor Dining Rooms, received re-inservice on Dining Room Meal Service protocols from the Director of Dining Services (8:00 AM for Breakfast, 12:15 PM for Lunch and 5:15 PM for Dinner). It is to be noted that Poplar and Maple Dining Rooms located on the 4th floor are seen by the Facility as one floor and are served from the same steam table.

II. Identification of Other Areas Potentially
Affected
The Director of Dining Services and the Director of Nursing did Rounds on the remaining Dining Room on the 3rd Floor to ensure compliance with Meal Service time/schedules. All identified concerns were corrected on the spot and in-services done as needed.

III. System Changes and Measures to Prevent
Reoccurrence
The Policy and Procedure on Meal Service was reviewed and found compliant. Dining Services and Nursing staff were re-inserviced on:
1. Preparing the trays for service to the residents timely. 8:00 AM Breakfast, 12:15 PM Lunch and 5:15 PM Dinner. Managers/Supervisors will be in the Dining Rooms 10 minutes prior to the meal times to accomplish all the necessary preparatory steps.
2. Sorting of meal tickets by Nursing prior to the start of the meal service and giving them to the Dining Services staff.
3. Timeliness of starting the beverage cart prior to meal service.
4. Recording of temperature on Pre-Service Form and reviewing of production sheets will be done prior to the Meal Service.
5. Delivery of the meal trucks to the Units timely so as not to adversely impact the start of the meal service.
6. Importance of all staff involved in the meal process,to arrive in the Dining Room timely.
7. Importance of serving ?In Room Trays,? within the scheduled time frame.
8. If alternates other than the main meals are required, residents will be notified that it will take additional time to prepare and could extend the length of the meal time.
9. New employees will be oriented on the Meal Service Policy.

IV. Monitoring of Corrective Action
1. An Audit Tool was developed by the Director of Dining Services and the Director of Nursing to ensure compliance during Meal Service. The Tool will be utilized by Nursing and Dining Services Supervisors/Managers to record negative findings in the Dining Rooms. Results on the Tool will be communicated to the Director of Dining Services and the Director of Nursing for follow up.
2. Dining Services Supervisors/Managers/Designee will monitor meal service daily during each meal to ensure ongoing compliance with all areas of the meal service. Areas of non-compliance will be addressed on the spot, and referred to the Director of Dining Services for follow up.
3. Nursing Supervisors/Managers/Designee will be present at least 10 minutes before the start of each meal to ensure compliance with our start time. Areas of non-compliance will be addressed on the spot, and referred to the Director of Dining Services for follow up.

V. QA Monitoring
The Director of Dining Services/Designee and the Director of Nursing/Designee will do a joint CQAI on Meal Service. Findings will be presented monthly to the CQAI Committee for six (6) months and then quarterly thereafter for twelve (12) months.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that doors protecting openings to hazardous areas were made self-closing and maintained to self-close. Reference is made to the kitchen door held open by a rice bin. The finding is: On (MONTH) 23, (YEAR) at approximately 1:30 p.m, during the annual life safety code recertification survey, it was observed that the door to the kitchen area in the basement in close proximity to C39B storage room was held open by a rice bin. In an interview with the food service director immediately after the finding, she stated that they held the door open to let smoke out from the area and immediately removed the bin from the door. 711.2(a)(1) 2000 NFPA 101 19.3.2.1
Based on observation and interview it was determined that the facility did not ensure that doors protecting hazardous areas were maintained to self-close as evidenced by doors to basements storage room and emergency exit from the boiler room that didn't close when tested and the laundry room door that had a broken self-closing device. The findings are: On 09/22/16 during the annual life safety recertification survey between 9:30 am and 3:30 pm, it was observed that doors to hazardous areas were not properly maintained to self-close. Examples include but are not limited to: - The storage room in the basement had numerous cardboard boxes with office supplies and the door to the corridor didn't self-close when tested . After several attempts, a facility staff closed the door by slightly pulling the door up. - The boiler room had a door to stairway 2 East alcove and the door didn't fully close and had to be pushed to close it. - The laundry room in the basement had a broken self-closing device. In an interview at approximately 1:40 pm with the director of safety and security (DSS), he stated that the identified doors will be fixed.

Plan of Correction: ApprovedOctober 20, 2016

K029
1. Corrective Action For Affected Areas
1. The Director of Food Service immediately removed the rice bin that wedged the door open in the Kitchen.
2. Adjustment was made to the Storeroom door in the Basement immediately to allow it to self-close.
3. The door closure by the Laundry Room in the Basement was replaced, allowing the door to self close.

II. Identification of Other Areas Potentially
Affected
1. All other doors in the Facility were checked by the Director of Engineering/Designee for Compliance. There were no other issues identified.

III. System Changes and Measures to prevent
Reoccurrence
1. The door in the Boiler Room by stairwell 2 was repaired immediately to allow it to close properly.
2. The Facility?s Policy and Procedure on ?Life Safety? was reviewed and found to be compliant. All staff will be rein-serviced on the policy regarding the Life Safety Codes. Lesson Plan will include:

a. No door should be wedged open with any object not approved or recommended by NFPA.

b. Doors should not be disconnected from self closure at any time.
c. Doors should close without any restrictions or manual assistance.
d. If there is a need for any door to be kept open, Engineering staff should be notified and an automatic door release device will be installed.

IV. Monitoring of Corrective Action
1. The Director of Engineering developed an audit tool to monitor all doors. The tool will be used by the Engineering staff to conduct daily audits. Engineering staff will inspect all doors during their Rounds to ensure that they are self closing when released from their magnet. Any door found out of compliance will be reported to the Director of Engineering for follow-up.

V. QA Monitoring
Findings will be presented by the Director of Engineering to the CQAI Committee monthly for six (6) months and quarterly thereafter for six (6) months.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Access to exits shall be marked by approved, readily visible signs in all cases where the exit or way to reach exit is not readily apparent to the occupants. Doors, passages or stairways that are not a way of exit that are likely to be mistaken for an exit have a sign designating "No Exit". 7.10, 18.2.10.1, 19.2.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: October 18, 2016

Citation Details

2000 NFPA 101: 7.10.1.2* Exits. Exits. Other than main exterior exit doors that obviously and clearly are identifiable as exits shall be marked by an approved sign readily visible from any direction of exit access. 7.10.8 No Exit. Any door, passage, or stairway that is neither an exit nor a way of exit axcess and that is located or arranged so that it is likely to be mistaken for an exit shall be identified by a sign that reads as follows: NO EXIT. Such sign shall have the word NO in letters 2in. (5cm)high with a stroke width of 3/8 in. (1.6cm)and the word EXIT below the word NO. Based on observation and staff interview, the facility did not ensure that only doors that lead to an exit access was marked by an exit sign. Reference is made to the door from the 2nd floor day room that leads to the smoking room that was marked with an approved exit sign. The Finding is: On (MONTH) 23, (YEAR) between the hours of 9:30 a.m and 3:00 p.m during the recertification survey, the following was observed: An EXIT sign was noted to be located in the second floor day room which directly leads to the smoking room. This egress would direct residents and staff into the smoking room which can jeopardize their safety. Additional signs in the same location that leed to the corridor for safe egress were also observed. On 1/23/16 at approximately 11:34 a.m, in an interview with the maintenance director, he stated that this concern would be corrected immediately. 2000 NFPA 101: 7.10.1.2, 7.10.1.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 20, 2016

K022
I. Corrective Actions for Affected Area
The Exit signage that was observed was immediately removed from above the Smoke Room door.

II. Identification of Other Areas Potentially
Affected
1. There is no other Smoke Room located in the Building.
2. All Exit signs in the Facility were checked to ensure that they do not lead into an area that can jeopardize the safety of residents and staff. Any signs found out of compliance will be removed and the door identified by a sign that reads ?NO EXIT.? This sign will be fabricated as per regulatory requirements and will include: ?NO? will be written in letters 2in. (5cm) high with a stroke width of 3/8 in. (1.6cm) and the word ?EXIT? below the word NO.

III. System Changes and Measures to Prevent
Reoccurence
1. The Policy and Procedure for Life Safety was reviewed and found to be in compliance. The Director of Engineering will rein-service all Engineering staff on the Policy and use of the Environmental Tool for Exit Signs. Sign-in Sheets will be filed for reference and validation.
2. Director of Engineering/Designee will check all Exit signs in the Facility weekly to ensure they are lit and that they are installed appropriately.
3. Security will check all Exit signs in the Facility weekly to ensure they are lit and that they are installed appropriately.

IV. Monitoring of Corrective Action
The Director of Engineering revised the Exit Sign Audit Tool to include ?Appropriateness of Installation.? The tool will be used weekly by the Engineering staff during Rounds to monitor all Exit signs. Any signs found out of compliance will be documented on the form and communicated to the Director of Engineering for immediate follow-up.

V. QA Monitoring
Findings will be presented by the Director of Engineering to the CQAI Committee Monthly for three (3) months then quarterly thereafter for twelve (12) months.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: September 27, 2016

Citation Details

1999 NFPA 70 National electrical Code Chapter 1 Article 110 Requirements for electrical installations 110-12 Mechanical execution of work. Electrical equipment shall be installed in a neat and workmanlike manner. (c) 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 adversely affect safe operation or mechanical strength of the equipment such as parts that are broken, bent, cut or deteriorated by corrosion, chemical action or overheating. Chapter 4 Equipment for general use. Article 400 Flexible cords and cables 400-8. Uses not permitted. Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure 2. Where run through holes in walls. structural ceilings suspended ceilings, dropped ceilings, or floors 3. Where run through doorways, windows or similar openings 4. Where attached to building surfaces Exception: Flexible cord and cable shall be permitted to be attached to building surfaces in accordance with the provisions of Section 364-8. 5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings or floors 6. Where installed in raceways, except as otherwise permitted in this Code Based on observation and interview it was determined that the facility did not ensure that electrical equipment was installed and maintained in accordance with NFPA 101 and NFPA 70 National Electrical Code. Reference is made to extension cords in use in the facility, improperly maintained receptacles and power cords installed in concealed areas above suspended ceilings in the facility including resident units. The findings are: On 09/22/16 during the annual life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that electrical equipment was improperly installed in the facility. Examples include but are not limited to: - Extension cords in use in room #s 293A and 282A and in the store room in the basement. - Loose receptacles in room # 380A and 2nd floor telephone closet. - A wall receptacle missing a faceplate in the basement store room. - The facility's smoking room had a fan and a smoke eliminator with power cords installed in concealed areas above the suspended ceiling. It should be noted that the facility had adopted the CMS categorical waiver on the safe use of electrical cords and adapters. In an interview on 09/22/16 at approximately 11:57 am, the FOD stated that all the extension cords were removed and that all electrical installations will be fixed. 10 NYCRR 711.2 (a)(1) NFPA 101 19.5.1, 9.1.2, 1999 NFPA 70 Arts 300 and 400.

Plan of Correction: ApprovedOctober 20, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K147
I. Corrective Actions for Affected Areas
1. The extension cords that were found in the Residents? rooms were removed immediately, along with the extension cord found in the Storeroom in the Basement.
2. The loose receptacle in room [ROOM NUMBER]A and also in the phone closet on the second floor were replaced immediately.
3. The faceplate for the receptacle in the storeroom in the basement was replaced immediately.
4. The wiring for the exhaust fan and the smoke eater in the smoking room on the second floor were rewired to be compliant.

II. Identification of Other Areas Potentially
Affected
Engineering staff were directed to check all Residents? rooms in the Facility for any extension cord that is non-compliant. Any, if present, should be removed immediately. They were also directed to look for any loose or missing faceplate on receptacles in the rooms and other areas in the building. No other non-compliant issues were noted.

III. System Changes and Measures to Prevent
Reoccurrence
Engineering staff are also instructed not to issue any extension cords to any department if they request it. The Facility purchased the appropriate CMS recommended Power strips and these were installed in areas where it?s deemed necessary. Audit Tool to be developed/updated.

IV. Monitoring of Corrective Action
Engineering staff have been instructed make daily rounds on the Units and look for any extension cords that may be present in the Residents?rooms and on the units. Engineering staff will ensure that all areas are in compliance. Non-compliant issues will also be reported to the Director of Engineering.

V. QA Monitoring
Findings will be reported by the Director of Engineering to the CQAI Committee monthly for six (6) months and then quarterly for twelve (12) months.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: November 21, 2016

Citation Details

Based on observation and interview it was determined that the facility did not ensure that the components of the automatic sprinkler system in the facility were maintained in accordance with NFPA 25 as evidenced by sprinklers with green discoloration (corrosion) and sprinkler with external load (conduit) in the facility's kitchen exit discharge to the loading dock area, sprinkler missing caps on 3rd fL recreation office and wires sitting on sprinkler pipes in the basement telephone closet. The findings are: On 09/22/16 during the annual life safety recertification code survey between 9:30 am and 3:30 pm, it was observed that a number of sprinkler heads were not properly maintained. Examples include but are not limited to: - sprinklers with green discoloration (corrosion) and sprinkler with external load (conduit) in the kitchen exit discharge to the loading dock area. - sprinkler missing caps on the 3rd floor recreation office. - wires sitting on sprinkler pipes in the basement telephone closet. In an interview on 09/22/16 at approximately 12:30 pm with the director of safety and security (DSS), he stated that the sprinklers with corrosion will be replaced, sprinkler caps will be installed and sprinkler pipes will be maintained free of wires or other external load. 711.2 (a)( 1)

Plan of Correction: ApprovedOctober 20, 2016

K062
I. Corrective Actions For Affected Areas
a) A service call was placed immediately to the fire alarm Vendor to replace the existing sprinklers with green discoloration on the Loading Dock. This will be done during the project to add additional sprinklers to the dock.
b) The external load (electrical conduit) was also relocated immediately away from the sprinkler head in the Kitchen exit discharge to the Loading Dock area.
c) The missing sprinkler cap on the third floor Recreation Office was replaced immediately.

d) The wires sitting on the sprinkler pipes in the Basement Telephone Closet were removed immediately and relocated.

II. Identification of Other Areas Potentially
All other areas and offices in the Facility were checked for sprinklers to ensure compliance. No other areas were found out of compliance.

III. System Changes and Measures to Prevent
Reoccurence
A survey was done in all Phone Closets, Electrical Closets and other areas where wires may be present to make sure that all sprinkler lines are free from any object hanging on it. Engineering staff were also directed to check all areas that have sprinklers installed and verify that there are no missing caps or corroded heads. Any areas found out of compliance will be reported to the Director of Engineering.

IV. Monitoring of Corrective Action
1. An Audit Tool was developed by the Director of Engineering to inspect all sprinkler heads in all areas in the building to ensure that they are installed properly, with no obstruction that will prevent the caps from dropping if the head is activated during a fire. Any areas found out of compliance will be reported to the Director of Engineering. Vendors and IT personnel will also be educated not to use the sprinkler lines to support any wires during installation.
2. During inspection of the fire alarm system, the Director of Engineering will request from the contracted fire alarm Vendor that they be vigilant and pinpoint any areas that may restrict the operations of the sprinkler heads if they are activated, and also to identify any that are rusted and corroded.

V. QA Monitoring
Findings will be presented by the Director of Engineering to the CQAI Committee monthly for three (3) months and then quarterly thereafter for eighteen (18) months.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 23, 2016
Corrected date: March 1, 2017

Citation Details

Based on observation and interview, it was determined that the facility did not ensure that an automatic sprinkler system was provided in all required areas in accordance with NFPA 13 and NFPA 25. Reference is made to the mechanical areas in the basement and the loading dock area under the more than 4 ft wide overhang that lacked sprinkler coverage. The findings are: On 09/22/16 during the annual life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that the facility's loading dock was located at the back of the nursing home building and the receiving area had an overhang of approximately 20 ft wide made of noncombustible material (concrete). It was also noted that combustible items such as wheelchairs, recliners, walkers, over bed tables, a handicap shower chair, cardboard boxes of approx. 5 ft x 15 ft and a full infections waste container were stored under the overhang. It was also observed that the loading dock area under the overhang was used for the delivery of combustible supplies to the facility. It was also observed that C07A-and C05- below the duct that were more than 4ft. wide in the engineering shop lacked sprinkler coverage. In an interview on 09/22/16 at approximately 12:45 pm, the director of safety and security (DSS) stated that the issue will be brought to the attention of the administrator. Subsequent interview with the Maintenance Director on the same day he stated that sprinkler protection will be provided in the required electrical areas. 2000 NFPA 101 - 19.3.5.1 1999 NFPA 13

Plan of Correction: ApprovedOctober 20, 2016

K056
I. Corrective Actions for Affected Areas
A service call was placed immediately to the contracted Fire alarm vendor (A. Automatic Sprinkler) to come and survey the loading dock and the ductwork in the Housekeeping Office and the Engineering shop, areas that lacked sprinkler coverage. Vendor inspected entire building and plans are in place to complete areas that were found out of compliance.

II. Identification of Other Areas Potentially
Affected
1. During Vendor?s visit, they were asked to inspect all other exterior areas to verify that sprinkler heads are installed and in compliance. A call was also placed to Dormitory Authority State of New York to send an authorized Fire Safety Inspector to assess the sprinkler coverage of our building in all areas.
2. During inspection of the fire alarm system, the contracted fire alarm Vendor will be advised to look for any location that requires the installation of a sprinkler head.

III. System Changes and Measures to Prevent
Reoccurence
Engineering staff are also reminded to do the same during their routine rounds, checking all electrical closets, phone closets, storage areas etc. Both parties will inform the Director of Engineering who will direct the fire alarm Vendor to install same. Any areas out of compliance will be reported to the Director of Engineering for immediate follow up.

IV. Monitoring of Corrective Action
The Director of Engineering/Designee will check for any location that may have a missing sprinkler head. He will concentrate more on the newly renovated areas that might have additional rooms built or existing rooms that might have had a sprinkler head and which may have been removed or covered up above the ceiling unintentionally.

V. QA Monitoring
Findings will be reported by the Director of Engineering to the CQAI Committee monthly for three (3) months and then quarterly thereafter for twelve (12)months.