New Carlton Rehab and Nursing Center, LLC
January 18, 2019 Certification Survey

Standard Health Citations

FF11 483.80(d)(1)(2):INFLUENZA AND PNEUMOCOCCAL IMMUNIZATIONS

REGULATION: §483.80(d) Influenza and pneumococcal immunizations §483.80(d)(1) Influenza. The facility must develop policies and procedures to ensure that- (i) Before offering the influenza immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered an influenza immunization October 1 through March 31 annually, unless the immunization is medically contraindicated or the resident has already been immunized during this time period; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of influenza immunization; and (B) That the resident either received the influenza immunization or did not receive the influenza immunization due to medical contraindications or refusal. §483.80(d)(2) Pneumococcal disease. The facility must develop policies and procedures to ensure that- (i) Before offering the pneumococcal immunization, each resident or the resident's representative receives education regarding the benefits and potential side effects of the immunization; (ii) Each resident is offered a pneumococcal immunization, unless the immunization is medically contraindicated or the resident has already been immunized; (iii) The resident or the resident's representative has the opportunity to refuse immunization; and (iv)The resident's medical record includes documentation that indicates, at a minimum, the following: (A) That the resident or resident's representative was provided education regarding the benefits and potential side effects of pneumococcal immunization; and (B) That the resident either received the pneumococcal immunization or did not receive the pneumococcal immunization due to medical contraindication or refusal.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interviews during the re-certification survey, the facility did not ensure the provisions for a total infection control program. Specifically: 1)The Pneumocococcal Immunization was not provided to Resident # 136 after consent from his representative was obtained. IFurther investigations revealed that the facility had not consistently offered or ordered pneumovaccination to newly admitted residents. The findings are: The facility's' Nursing Home Guidelines (not dated), for standing order of pneumococcal vaccines (PPV), documented, .that each residents pneumococcal status will be determined upon admission or soon afterwards .and will be documented in the residents medical record . 1) Resident # 136's representative signed a consent form authorizing the facility to administer the pneumoccal vaccination ([MEDICATION NAME]) on 9/24/18. There is no documented evidence in the resident's medical record indicating that the resident received the vaccination. Surveyors observed no pneumoccocal vaccines stored in the facility for any residents. A review of medical records of a sample of newly admitted residents revealed that no residents received the pneumovaccinaton. The Assistant Director of Nursing (ADON) was interviewed on 01/18/19 at 09:42 AM and stated that he is the responsible person for maintaining an effective and ongoing Infection Control Program, (ICP). He has had this responsibility since (MONTH) (YEAR). He stated that the goal of an effective ICP is to prevent illness and to keep staff and residents from becoming ill. The ADON stated in November, (YEAR), he began an audit for the collection of data upon medical record reviews to determine what residents had received and what residents had not received the pneumococcal vaccine. He stated that he found that the pneumococcal vaccines were last offered around 2013. The ADON stated that he began to keep a record for those residents who required a booster to then begin offering the vaccine. He stated that for the newly admitted residents, none have received the vaccine at this present time. He stated that he was waiting for further data collection on his part, to then request the vaccines. He stated that he formulated a letter, requesting consent of the vaccines, including risk and benefits which were sent out to families. The ADON stated that there are currently no pneumococcal vaccines available for distribution now. When asked about why the newly admitted had not been given the vaccine, he stated that he was waiting to collect more data, and stated that the vaccines will be offered to the newly admitted residents. 415.19(a)(1)

Plan of Correction: ApprovedMarch 5, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1 - The resident in question, who had already had a consent signed, was given the appropriate pneumococcal injection. 2/7/19

Element #2 - All residents who have given consent and are appropriate to receive the pneumococcal vaacine could potentially be affected by this deficient practice. All residents identified as having given consent were included in the audit indicated in #3 below. All residents given consent and who were identified as due for either of the pneumococcal vaccines will receive the vaccine 03/08/19.
Element #3 - The policy and procedure for the administration of pneumococcal vaccine was reviewed and updated. The DNS and ADNS commenced an audit of all residents to determine if and when a resident received pneumococcal vaccine, and if the resident did receive pneumococcal, which type did the resident receive. Utilizing this data, the DNS and ADNS are developing a spread sheet. This sheet will include the date and type of last given pneumococcal, or if there is no indication that the resident ever received pneumococcal. Utilizing this data the spreadsheet will also have data entered to indicate if and when and what type of pneumococcal will next be required. In addition, all new admission data will be screened to ascertain if and when and what type of pneumococcal was given and these resident will be entered onto the spreadsheet. Pneumococcal will be ordered form the pharmacy, as needed, as it is provided in a patient by patient vial. At the most it will take 24 hours for the product to arrive.
On admission, readmission, after a significant change and quarterly, the Physician will review the total plan of care, particularly the resident Preventative Health Maintenance Plan of Care.
This includes:
- Vaccines: Pneumonia, Influenza, [MEDICAL CONDITION] others as
appropriate
- Health Screenings appropriate for age: mammography, PSA, stool
for occult blood, and others, as appropriate.
The Physician will review the items above, ensuring that consent for and actual provision of the appropriate items are up to date for the age and acuity of the resident. Any consents yet to be completed will be referred to the ADON and Social Worker, and followed up by the Physician.
Element #4 - The DNS or designee will review the spreadsheet by the third week of the previous month to determine who is due for pneumococcal during the following month. The DNS will review all charts of residents who are triggered as coming due for pneumococcal during the month to ensure an MD order, and that there is consent given and will review three random charts monthly, on the last day of the month, to ensure that those residents who triggered as being due for pneumococcal actually received it. 3/8/19
The Medical Director will audit the Preventative Health Maintenance Plan of Care on a monthly basis for 6 months, then quarterly, for completeness. New admissions will be referred to the Medicaid Director for ongoing audit on a monthly basis.
All professional staff will be In-serviced regarding the current policy and procedure for administration of pneumococcal vaccine. 3/8/19
Element #5 - The DNS or designee will report quarterly to the QA Committee the results of the on-going pneumococcal administration program to ensure that all residents are receiving the pneumococcal as needed. 3/8/19

FF11 483.10(g)(17)(18)(i)-(v):MEDICAID/MEDICARE COVERAGE/LIABILITY NOTICE

REGULATION: §483.10(g)(17) The facility must-- (i) Inform each Medicaid-eligible resident, in writing, at the time of admission to the nursing facility and when the resident becomes eligible for Medicaid of- (A) The items and services that are included in nursing facility services under the State plan and for which the resident may not be charged; (B) Those other items and services that the facility offers and for which the resident may be charged, and the amount of charges for those services; and (ii) Inform each Medicaid-eligible resident when changes are made to the items and services specified in §483.10(g)(17)(i)(A) and (B) of this section. §483.10(g)(18) The facility must inform each resident before, or at the time of admission, and periodically during the resident's stay, of services available in the facility and of charges for those services, including any charges for services not covered under Medicare/ Medicaid or by the facility's per diem rate. (i) Where changes in coverage are made to items and services covered by Medicare and/or by the Medicaid State plan, the facility must provide notice to residents of the change as soon as is reasonably possible. (ii) Where changes are made to charges for other items and services that the facility offers, the facility must inform the resident in writing at least 60 days prior to implementation of the change. (iii) If a resident dies or is hospitalized or is transferred and does not return to the facility, the facility must refund to the resident, resident representative, or estate, as applicable, any deposit or charges already paid, less the facility's per diem rate, for the days the resident actually resided or reserved or retained a bed in the facility, regardless of any minimum stay or discharge notice requirements. (iv) The facility must refund to the resident or resident representative any and all refunds due the resident within 30 days from the resident's date of discharge from the facility. (v) The terms of an admission contract by or on behalf of an individual seeking admission to the facility must not conflict with the requirements of these regulations.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record review during the recertification survey, the facility did not provide the appropriate liability to Medicare beneficiaries. Specifically, the facility did not provide residents/representatives with Notice of Medicare Non-Coverage (NOMNC) at the termination of Medicare Part A benefits. This is evident for 1 of 3 residents reviewed for Skilled Nursing Facility beneficiary protection notification out of a sample size of 27. The findings include: The undated policy and procedure Family Notification document all attempts to reach the responsible party will be documented in the residents' chart by Social Worker and/or Registered Nurse. Resident #65 was admitted [DATE] and had [DIAGNOSES REDACTED]. The Quarterly Minimum Data Set ((MDS) dated [DATE] assessment documented the resident with short and long term memory problem. The Skilled Nursing Facility (SNF) Beneficiary Protection Notification Review form (form CMS - ) provided for Resident #65 documented Medicare Part A skilled services began 8/22/18 and the last covered day was 11/8/18. The form documented the facility/provider initiated discharge from Medicare Part A Services when benefit days were not exhausted. The NOMNC form dated 11/6/18 documented the patient is unable to comprehend significance of NOMNC. The NOMNC form contained the signature of the Director of Social Services and was not signed by either the resident or the resident's representative. On 01/17/19 at 10:33 AM, an interview was conducted with the Director of Social Services (DSS) who stated the role of the social services department is to ensure that the information is explained clearly to the resident/family enabling them to make the right choices. The DSS stated resident #65 is very confused and severely demented. The DSS stated the form was not sent to the next of kin and could not recall why. She further stated that representatives are contacted via telephone and consent is obtained verbally but she does not document the communication in the medical record. The DSS stated that forms are not sent to the representative because many times the forms are not returned to the facility. These discussions are not currently being documented in the medical record and the department would have to begin to document the content of these conversations. On 01/18/19 at 12:20 PM, the DSS stated alert residents are spoken to directly while representatives of non cognitive residents are contacted via the telephone. The DSS stated there is no documentation and was not told to document. 415.3 (g)(2)(i)

Plan of Correction: ApprovedFebruary 27, 2019

Element #1 - Letter indicating notice of Medicare non-coverage sent via mail, to next of kin.
Element #2 - All residents whose payor source was changed from Medicare to some other payor source are potentially subject to this deficient practice.
Element #3 - We reviewed all changes in Medicare payment source for past six months. All NOK and/or residents were notified appropriately. Finance will add one column to the Census tracking book to indicate the day letter was generated and given to Social Worker.
Element #4 - Social worker will keep a tracking log indicating the day letter was received from finance and the day letter was mailed to NOK or given to resident. Administrator will audit this book weekly to ensure that as per requirement anytime there is a change in payor source from Medicare a notice of non coverage has been issued to NOK or patient. The Administrator will gather the quarterly statistics. There is a zero rate of acceptance for non-coverage letters to be generated and given when there is a change in payor status from Medicare.
Element #5 - This monitoring by Administrator will be on-going and will be reported to the QA Committee.quarterly

FF11 483.30(b)(1)-(3):PHYSICIAN VISITS - REVIEW CARE/NOTES/ORDER

REGULATION: §483.30(b) Physician Visits The physician must- §483.30(b)(1) Review the resident's total program of care, including medications and treatments, at each visit required by paragraph (c) of this section; §483.30(b)(2) Write, sign, and date progress notes at each visit; and §483.30(b)(3) Sign and date all orders with the exception of influenza and pneumococcal vaccines, which may be administered per physician-approved facility policy after an assessment for contraindications.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record reviews and interview during the re-certification survey, the facility did not ensure that the physician review the residents total program of care. Specifically: The physician did not ensure that the pneumococcal vaccine was provided to Resident #136, despite consent being given by the resident's representative. In addition there was no evidence that the attending physician's were assessing newly admitted or other residents for potential administering of Pneumococcal vaccine. The findings are: 1) Resident # 136's representative signed a consent form authorizing the facility to administer the pneumococcal vaccination ([MEDICATION NAME]) on 9/24/18. There is no documented evidence in the resident's medical record indicating that the resident received the vaccination. On 01/18/19 at 12:51 PM the Medical Director was interviewed and stated the following. The Pneumococcal Vaccines (PPV) should have been ordered. As part of the admission process, the physician will assess the resident and offer the vaccine. It is the physician's responsibility to order these vaccines, especially for person with chronic diseases, including the elderly, persons with diabetics and person with Chronic [MEDICAL CONDITION] Obstructive Diseases ([MEDICAL CONDITION]) to prevent all kinds of infections, especially in susceptible residents. We recently had a quarterly meeting that included the pharmacist to discuss protocols. The protocol consists of ordering and recommending the PPV upon admission, upon the first monthly resident assessments and upon the first annual examination for the health and maintenance of our residents. We had an audit recently that included the infection control personnel and we focused mostly on administering the flu and given the high cases of influenza this season. The PPV should have been made available for new residents as they were not a part of our audits. Ultimately it is the physicians' responsibility to ensure that that necessary vaccines are available and offered to our residents.

Plan of Correction: ApprovedMarch 5, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Element #1 - The resident in question, who had already had a consent signed, was given the appropriate pneumococcal injection. 2/7/19

Element #2 - All residents who have given consent and are appropriate to receive the pneumococcal vaacine could potentially be affected by this deficient practice. All residents identified as having given consent were included in the audit indicated in #3 below. All residents given consent and who were identified as due for either of the pneumococcal vaccines will receive the vaccine 03/08/19.
Element #3 - The policy and procedure for the administration of pneumococcal vaccine was reviewed and updated. The DNS and ADNS commenced an audit of all residents to determine if and when a resident received pneumococcal vaccine, and if the resident did receive pneumococcal, which type did the resident receive. Utilizing this data, the DNS and ADNS are developing a spread sheet. This sheet will include the date and type of last given pneumococcal, or if there is no indication that the resident ever received pneumococcal. Utilizing this data the spreadsheet will also have data entered to indicate if and when and what type of pneumococcal will next be required. In addition, all new admission data will be screened to ascertain if and when and what type of pneumococcal was given and these resident will be entered onto the spreadsheet. Pneumococcal will be ordered form the pharmacy, as needed, as it is provided in a patient by patient vial. At the most it will take 24 hours for the product to arrive.
On admission, readmission, after a significant change and quarterly, the Physician will review the total plan of care, particularly the resident Preventative Health Maintenance Plan of Care.
This includes:
- Vaccines: Pneumonia, Influenza, [MEDICAL CONDITION] others as
appropriate
- Health Screenings appropriate for age: mammography, PSA, stool
for occult blood, and others, as appropriate.
The Physician will review the items above, ensuring that consent for and actual provision of the appropriate items are up to date for the age and acuity of the resident. Any consents yet to be completed will be referred to the ADON and Social Worker, and followed up by the Physician.
Element #4 - The DNS or designee will review the spreadsheet by the third week of the previous month to determine who is due for pneumococcal during the following month. The DNS will review all charts of residents who are triggered as coming due for pneumococcal during the month to ensure an MD order, and that there is consent given and will review three random charts monthly, on the last day of the month, to ensure that those residents who triggered as being due for pneumococcal actually received it. 3/8/19
The Medical Director will audit the Preventative Health Maintenance Plan of Care on a monthly basis for 6 months, then quarterly, for completeness. New admissions will be referred to the Medicaid Director for ongoing audit on a monthly basis.
All professional staff will be In-serviced regarding the current policy and procedure for administration of pneumococcal vaccine. 3/8/19
Element #5 - The DNS or designee will report quarterly to the QA Committee the results of the on-going pneumococcal administration program to ensure that all residents are receiving the pneumococcal as needed. 3/8/19

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that corridor doors to resident rooms were maintained to close properly and latch in their door frames. Reference is made to the corridor door to the resident room #s 415, 312 and 207, that did not latch and close in their door frames. The findings include: On (MONTH) 14 and (MONTH) 15, 2019 at 10:00 AM to 3:00 PM, it was observed that the doors to a number of resident rooms were not maintained to close and positively latch in their door frames. Examples were room #s 415, 312 and 207. The latching devices of the doors remain retracted and did not protrude to latch into their door frame. The doors were either hitting the door frames or were dragging on the floor preventing them from positively latching. On (MONTH) 15, 2019 at approximately 11:00 AM, the facility's Maintenance Assistant stated that all rooms will be checked and repaired so as to close and properly latch in the door frame. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - The doors in question could not be remedied . Therefore, we contacted a door company to measure and install new doors that would meet the required standard. 1/23/19
Element #2 - All doors could be subject to this deficient practice. However, during the Recertification Survey every door was inspected, and these three cited doors were the only ones noted to not meet the required standard. 1/23/19
Element #3 - We are proceeding with the installation of new doors in the cited areas. In addition , all doors will be checked bi-monthly, during maintenance rounds to ensure that they continue to meet applicable requirements. 2/15/19
Element #4 - The Administrator will randomly check five doors,
bi-monthly, for three months to ensure compliance with standards that they latch and close int their door frames. 2/8/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, staff interview and record review, it was determined that the facility did not ensure that all electrical equipment used for patient care was maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that all electrical equipment was inspected or tested as per policies and protocols established by the facility. Examples were oxygen concentrators , mattress pumps, electric beds,and suction machines that were not consistently provided with inspection tags/inspection stickers. The findings include: On (MONTH) 14 and (MONTH) 15, 2019 between the hours of 10:00 AM to 3:00 PM, during the annual recertification survey of the facility, it was observed that the facility had provided a number of resident care electrical equipment for resident care in the resident rooms or in other areas of the facility. An interview with the facility's Maintenance Personnel revealed that the facility had a policy for inspecting all resident care electrical equipment, either by an outside agency or by the facility maintenance department. Per the policy inspection stickers are to be affixedto the equipment when inspected at established intervals. Nevertheless, a number of resident care electrical equipment , including but not limited to the following, were not provided with inspection stickers. 1. In room [ROOM NUMBER], a mattress pump and a feeding pump lacked the inspection stickers. 2 On the 4th floor, an electrical suction machine, located in the dining area, lacked an inspection stickers 3. A Covidien electric feeding pumps, on the 4th floor, lacked the inspection stickers. On (MONTH) 15, 2019, at approximately 12:15 PM, the facility's Maintenance Assistant stated that facility will contact the outside agency responsible for inspecting the resident care electrical equipment to inspect and provide inspection stickers for all resident care electrical equipment in accordance with NFPA 99. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - The items mentioned in the SOD were inspected and tagged as per policy. 1/22/19
Element #2 - All electrical equipment used for resident care are potentially subject to this same deficient practice. 1/22/19
Element #3 - A new log book will be utilized. The log book will be patient by patient. Each piece of electrical equipment utilized by the specific patient will be logged onto this tracking sheet. It will be noted on sheet how often equipment needs to be inspected per the manufacturers recommendation. As each piece of equipment is inspected it will be notated in tracking book and entered onto an adhesive sticker placed on the piece of equipment. 2/15/19
Element #4 - Administrator will review ten pieces of electrical equipment, monthly, and compare the date on the tracking sheet and on the sticker on the piece of equipment to ensure compliance. This will continue for a period of three months. 2/15/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

REGULATION: Hazardous Areas - Enclosure Hazardous areas are protected by a fire barrier having 1-hour fire resistance rating (with 3/4 hour fire rated doors) or an automatic fire extinguishing system in accordance with 8.7.1 or 19.3.5.9. When the approved automatic fire extinguishing system option is used, the areas shall be separated from other spaces by smoke resisting partitions and doors in accordance with 8.4. Doors shall be self-closing or automatic-closing and permitted to have nonrated or field-applied protective plates that do not exceed 48 inches from the bottom of the door. Describe the floor and zone locations of hazardous areas that are deficient in REMARKS. 19.3.2.1, 19.3.5.9 Area Automatic Sprinkler Separation N/A a. Boiler and Fuel-Fired Heater Rooms b. Laundries (larger than 100 square feet) c. Repair, Maintenance, and Paint Shops d. Soiled Linen Rooms (exceeding 64 gallons) e. Trash Collection Rooms (exceeding 64 gallons) f. Combustible Storage Rooms/Spaces (over 50 square feet) g. Laboratories (if classified as Severe Hazard - see K322)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that hazardous areas were separated from other parts of building with at least smoke resistive construction. Reference is made to the enclosure walls to the recreation storage room, and the enclosure walls to the dietary storage rooms that were not extended to the ceiling above so as to resist the passage of smoke. The finding include : On (MONTH) 14 and (MONTH) 15, 2019, between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that two facility hazardous areas (storage rooms) were provided with an automatic fire extinguishing system but lacked a smoke resistant enclosure. The enclosure walls to the recreation storage room adjacent to the conference room were not extended to the ceiling above so as to provide at least a smoke resistant enclosure. The enclosure walls to the dietary storage area, off the physical therapy area in the basement, were not extended to the ceiling above so as to provide at least the smoke resistant enclosure to the physical therapy area On (MONTH) 15, 2019 at approximately 11:30 AM, the facility's Maintenance Assistant stated that enclosure walls to the storage rooms will be extended to the ceiling so as to provide smoke resistant enclosure and prevent smoke penetration to other parts of the building. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - The smoke resistant materials needed to provide a smoke resistant enclosure to the recreation storage area were ordered. A decision was made to remove the enclosure completely form the dietary storage area. 01/21/19
Element #2 - Any area in the building that had an enclosure constructed could be subject to this deficient practice. 01/21/19
One other area was noted - the Physical Therapy Office. All cardboard and any other flammable material will be removed and either stored in metal cabinets or stored in a properly enclosed location. 02/06/19
Element #3 - There are no other locations subject to this deficient practice. The physical therapist has been In-serviced regarding the prohibition against storing anything flammable or hazardous within the physical therapy office. 02/06/19
Element #4 - The Administrator will randomly, at least once
bi-weekly for three months, inspect the physical therapy officed to ensure there is no storage of hazardous materials. 02/08/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

K307 NFPA 101:MEANS OF EGRESS - GENERAL

REGULATION: Means of Egress - General Aisles, passageways, corridors, exit discharges, exit locations, and accesses are in accordance with Chapter 7, and the means of egress is continuously maintained free of all obstructions to full use in case of emergency, unless modified by 18/19.2.2 through 18/19.2.11. 18.2.1, 19.2.1, 7.1.10.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

Based on observation, it was determined that the facility did not ensure that the exit access corridor/exit passageways were maintained free of combustible and other storage that would interfere with the safe use of the corridors during a fire or other emergency. Reference is made to the storage of large quantities of cartoned supplies in the egress corridor leading to stairs in the basement. The findings include: On (MONTH) 14 and (MONTH) 15, 2019, at 10:00 AM to 3:00 PM, it was observed that the facility was storing approximately 20 cartons of supplies in the exit corridors leading to the front and rear exit stairways in the basement. Such storage in the exit access corridor would make the corridor impassable during fire or other emergency. All means of egress are to be maintained free of any storage that would interfere with the safe usage of the egress path by the building occupants during a fire or other emergency. On (MONTH) 15, 2019, at approximately 12:30 PM, the facility's maintenance assistant stated that all combustible cartoned supplies will be removed from the egress corridor and stored in a suitable enclosed storage room 711.2(a)(1) 2012 NFPA 101 .

Plan of Correction: ApprovedFebruary 7, 2019

Element #1- Combustible materials were immediately removed from the cited areas on 01/21/19.
Element #2 - Any areas of egress are potentially subject to this deficient practice. 01/21/19
Element #3 - Inspection of areas of egrees to ensure they are maintained free of anything that would serve as an obstruction revealed there were no other areas with such obstructions. 01/21/19
Element #4 - Inspection of all areas of egrees to ensure they are free of obstruction has been added to bi-monthly maintenance checklist. Administrator will randomly select two such areas from the bi-monthly checklist and inspect for confirmation. 02/7/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

K307 NFPA 101:SMOKE DETECTION

REGULATION: Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

Based on observation and staff interview, it was determined that the facility did not ensure that the open space to the corridor were provided with a smoke detection system as per 2012 NFPA 101 19.3.6.1. Reference is made to the television area/residents sitting area on the 2nd floor , that was open to the corridors, and lacked a smoke detection system The findings include : On (MONTH) 14 and (MONTH) 15, 2019, between 10:00 AM and 3:00 PM, during the recertification survey of the facility, it was observed that the on the 2nd floor, the television area/residents sitting area was open to the corridor. The sitting area lacked the required smoke detection system as per 2012 NFPA 101 19.3.6.1. On (MONTH) 15, 2019, at approximately 11:45 AM, the facility's Maintenance Assistant stated that that open areas to the egress corridor will be provided with the required smoke detection system. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - We installed a smoke detector in the cited location. 1/22/19
Element #2 - Any areas that are open to egress corridors could be subject to this deficient practice. 1/22/19
Element #3 - Smoke detectors are inspected, minimally semi-annually, by our electricians to ensure they are in good working order. Battery powered smoke detectors will beep if battery is dying. We have an ample supply of smoke detectors and batteries to use as the situation warrants it. In addition, the inspection of smoke detectors is added to the bi-monthly maintenance audit sheet for review by the Administrator. 2/8/19
Element #4 - As there are no other areas that are in need of smoke detectors, as indicated at both the Recertification Survey and the maintenance rounds, there is no likelihood that this deficient practice could recur. 2/5/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 2012 NFPA 101 9.7 and NFPA 13. Reference is made to the lack of sprinkler coverage for a number of areas in the building, examples include : the elevator machine room, on the roof, lacked sprinklers; the rear shower room, on 2nd floor, lacked sprinklers; cubicle curtains in a number of room were obstructing sprinklers; sprinklers were obstructed by large columns in the laundry room and in the conference room; concealed sprinklers, lacked cover plates; a section of room [ROOM NUMBER], beneath the large ceiling pocket, had sprinkler approximately 12 feet from the wall; obstructed sprinkler by high soffit in room [ROOM NUMBER]; sprinkler pipe in room [ROOM NUMBER] A, lacked sprinklers; the recessed alcove in male toilet room on the first floor, lacked sprinkler coverage ; storage area under the overhang in the housekeeping storage room , lacked sprinkler coverage ; and the sprinkler was obstructed with solid curtain in the male toilet/shower area across room [ROOM NUMBER]. The findings include: On (MONTH) 14 and (MONTH) 15, 2019 , between 10:00 AM and 3:00 PM, during the recertification survey, it was observed that in a number of areas of the building examples include but are not limited to the following areas, lacked sprinklers, or the existing sprinklers were obstructed, so as not to provide coverage for the entire protected area : (1) The elevator machine room, on the roof, lacked sprinklers. A vertical pipe (appeared to be sprinkler pipe), in the room, was noted with capped end. (2) The central toilet/bathing area at the rear of 2nd floor, the shower stall lacked sprinkler. (3) In a number of resident rooms, the sprinklers were obstructed with cubicle curtains that had less than 18 inches mesh on the top, examples were : room #'s 412, 414, 407, 405 and 403. (4) In the laundry room and in the conference room, in the basement, the existing sprinklers were obstructed by approximately 21 inches wide construction columns, so as not to provide coverage for the entire protected area. (5) A number of concealed sprinklers lacked their cover plates, examples were : the rear central toilet room , on 2nd floor; the records storage room, in the basement, and the walk-in refrigerator in the kitchen. (6) In room [ROOM NUMBER], the sprinkler installed in the section of room located under the deep ceiling pocket, was approximately 12 feet from the wall, instead of the maximum of 6 feet from the wall. (7) In room [ROOM NUMBER], an upright type sprinkler was obstructed by approximately 14 inches high soffit ; so as not to provide coverage for the entire protected area. (8) In room [ROOM NUMBER] A, a supporting hanger was lacking for sprinkler pipe longer than three feet between the last hanger and the last sprinkler. The sprinkler pipe lacking hanger was approximately four feet long between the last hanger and the last sprinkler. (9) In the male toilet room, adjacent to room [ROOM NUMBER], the recessed alcove containing handwashing sink, a lighting fixture above the sink and waste basket was not covered with automatic extinguishing system. The existing sprinklers in the vicinity of the alcove was obstructed by the turn of the wall, so as not to provide protection for the alcove. A sprinkler was not provided in front or within the recessed alcove. (10) In the housekeeping storage room, in the basement, the storage space under an approximately three and half feet wide overhang was not covered with automatic extinguishing system. The existing sprinkler in the vicinity of the overhang was obstructed by an approximately 30 inches high soffit, so as not to provide coverage for the storage space under the overhang On,January 15, 2019 at approximately 12:00 PM, the facility's maintenance assistant stated that the sprinkler company will be contacted to evaluate and provide automatic sprinklers throughout the building, as per NFPA13. The Maintenance Assistant further stated that sprinkler company could not install water based sprinklers in the elevator machine room, as such system was not acceptable to the local fire department. The assistant and the facility administration stated that an approved alternate fire extinguishing system will be installed in the elevator machine room. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 13 .

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - We immediately contacted our Sprinkler monitoring company to request they come to facility to survey the cited areas and to provide us with a proposal to install the required sprinklers. 1/25/19
Element #2 - The entire building could potentially be affected by this deficient practice. 1/25/19
Element #3 - The sprinkler company came into the building and did an audit of the location of the systems head. All areas cited in the SOD will be corrected . A proposal has been accepted and work should be completed by Feb. 8, 2019. In addition, new cubicle curtains have been ordered that will have at least 18 inches of mesh on the top. 2/8/19
Element #4 - As the building was thoroughly inspected, both during the recertification Survey and by our Primary Sprinkler Company, it does not appear that this deficient practice could recur. 2/8/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: February 15, 2019

Citation Details

Physical Plant - State Violations Only NYCRR 713-1.9 (d): Bathing rooms, soiled workrooms, soiled linen rooms and Janitors' closets shall have mechanical exhaust ventilation or a wall or, if approved by the department, window exhaust fan with back draft louvers. This standard is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that the central bathing rooms on the 3rd floor was provided with functional mechanical exhaust ventilation system. Reference is made to the wall exhaust fan installed in the 3rd floor central bathing area that was not functioning. This occured on one floor of the facility. The findings include: On (MONTH) 14 and (MONTH) 15, 2019, at 10:00 AM to 3:00 PM, it was observed that the facility had installed a wall mounted exhaust fan in the front central bathing room, on the 3rd floor. The wall exhaust fan was not maintained in functional order. On (MONTH) 15, 2019, at approximately 1:00 PM, the facility's Maintenance Assistant stated that the exhaust fan was disconnected during the reconstruction of the bathing room. The Assistant further stated that the wall exhaust fan will be repaired to operate as designed.

Plan of Correction: ApprovedFebruary 7, 2019

Element #1 - The exhaust fan in question needed to be replaced. It was ordered and replaced as soon as it was received. 1/28/19
Element #2 - All exhaust fans are subject to this deficient practice. 1/21/19
Element #3 - The checking of exhaust fans has been added to the maintenance bi-monthly rounds audit sheet. Fans will be replaced as the need arises. 2/5/19
Element #4 - Administrator will randomly check two exhaust fans bi-monthly, for three months, to ensure compliance with this P(NAME). 2/15/19
Element #5 - This citation and the on-going monitoring of the P(NAME) will be reported to and discussed at quarterly QA Meeting to ensure on going compliance.