Dumont Center for Rehabilitation and Nursing Care
July 11, 2017 Certification Survey

Standard Health Citations

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (d) A provider may temporarily approve a prospective employee while the results of the criminal history record check are pending. The provider shall implement the supervision requirements identified in section 402.4 of this Part, applicable to the provider, during the period of temporary employment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 28, 2017

Citation Details

Based on record review and interview conducted during a recertification survey, the facility did not ensure that 1 of 2 prospective employees (#1) subjected to Criminal History Record Checks (CHRC) was properly supervised prior to receipt of a negative determination finding to protect and promote the safety of residents. The findings are: The facility's CHRC system was reviewed on 7/11/17. There was no documented evidence that the facility supervised Employee #1 while awaiting the results of the CHRC. Employee #1 was hired on 6/8/16. The facility received a pending denial letter dated 6/14/16 for Employee #1, a housekeeping aide, who had contacts with residents, which indicated that the employee had open charges that resulted in CHRC denial. According to the pending denial letter, an individual must be immediately terminated from direct patient care service pending CHRC clearance. The facility provided a copy of Employee #1's time card and revealed that Employee #1 worked on 6/12/16 and 6/13/16. The pending denial letter was then received by the facility on 6/14/16 . There was no documented evidence that Employee #1 was supervised from the date of hire up to 6/13/16. The facility then provided a letter dated 6/17/16, sent to the DOH (Department of Health), regarding its decision to keep Employee #1 for employment. The facility subsequently received a letter from the DOH dated 11/18/16 clearing Employee #1 for employment. The Human Resources Director (HRD) who was responsible for administering the facility's CHRC program was interviewed on 7/11/17 at 3:11 PM and stated that the employee was not supervised because the Housekeeping Director was on vacation. The HRD stated that when the negative letter was received on 6/14/16, Employee #1 was kept off duty. 402.9(b)(2)

Plan of Correction: ApprovedJuly 18, 2017

1- Employee number 1 was removed from the system on 6-14-16 and was not put back on the schedule until a determination letter of clearance was received on 11-18-16.
2- All employees who were still being monitored by the supervisor/designee during the week of (MONTH) 11th (YEAR) were switched to the updated provisional form. The updated form includes the day and shifts the individual worked for that respective week.
2A - The provisional form will be signed by the supervisor/designee no later than the Monday following the current week. In the case of holiday on the that Monday, the form will be signed by the supervisor/designee on the Tuesday following the Holiday.
3- The Administrator and Assistant Administrator/HR updated the policy to include the signature of the supervisor/designee for each day for the respective week. The provisional form was updated as well to include the date and shift the employee worked during that respective week.
4- The Administrator created an audit tool to ensure compliance with the plan of correction. Any negative findings will be corrected immediately by the Administrator/Designee. Findings will be reported to the QA Committee at a minimum of three months or as often to ensure compliance. The Administrator is responsible for ensuring the compliance.

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which 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; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 28, 2017

Citation Details

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that proper hand hygiene was followed to prevent contamination and spread of infection and cross contamination. Specifically, a Certified Nursing Assistant (CNA) on the First Floor Unit did not perform proper hand hygiene between residents during a lunch meal observation. The findings are: A lunch meal observation was conducted on 7/5/17 at 12:12 PM to 12:35 PM on the First Floor dining room. The following was observed as the same CNA went from the dining room to the residents' room: - The CNA applied a clothing protector on Resident #194, moved the resident's wheelchair and repositioned her in the wheelchair. The CNA then touched the tip of the straw with her bare hands prior to placing it in a container of juice. The CNA then set up another resident's lunch meal tray in the dining room, without performing any hand hygiene. - Before assisting the next resident (#272) during this lunch meal in the dining room, the CNA did not perform any hand hygiene. The CNA continued to touch this resident's eating utensils, including placing straw in a container of juice without using any barrier between her hands and the aforementioned utensils. - The CNA then exited the dining room and proceeded to Resident #47's room to assist the resident. The CNA touched the resident's skin, elevated the head of the bed, and adjusted the bed linens with her bare hands, and prepared the resident's lunch meal tray without performing any hand hygiene. The CNA then exited the room without performing proper hand hygiene. - The CNA then went directly to Resident #130's room without performing proper hand hygiene before assisting this resident. The CNA used her bare hands to adjust this resident's bed, touched her skin, clothes, and bed linens. The CNA then exited the room without washing or sanitizing her hands, and went directly to the dining room and took the meal trays from the food cart to serve other residents. The CNA was interviewed on 7/5/17 at 1:15 PM and stated she was not aware of what she did. The CNA stated that she should have washed her hands between residents. 415.19(a) (1-3)

Plan of Correction: ApprovedJuly 21, 2017

1. On 7-12-17, the ADNS/Inservice Coordinator provided the involved CNA a re-education on hand hygiene, emphasizing when it is required and its importance. The ADNS/Inservice Coordinator also counselled the involved CNA.
2- All residents have potential to be affected.
3- The DNS reviewed and confirmed the facilities policy and procedure on hand hygiene. The DNS created an audit tool for hand hygiene before meal service. The ADNS/Inservice Educator will re inservice all the staff on the facilities policy and procedure on hand hygiene. The ADNS/designee will conduct hand hygiene competency evaluation to all the staff members.
4- The ADNS/Designee will conduct a meal audit daily for one week and monthly thereafter. ANy negative findings will be corrected immediately by the ADNS/Designee. The ADNS/Designee will report the findings of the audit to the QA Committee quarterly at a minimum or as often as needed to assure compliance. The DNS is responsible for ensuring the compliance.

FF10 483.90(g)(2):RESIDENT CALL SYSTEM - ROOMS/TOILET/BATH

REGULATION: (g) Resident Call System The facility must be adequately equipped to allow residents to call for staff assistance through a communication system which relays the call directly to a staff member or to a centralized staff work area - (2) Toilet and bathing facilities.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that the call light system was functioning for residents to call for staff assistance if needed. Specifically, the call bell system, in a shared bathroom, on unit 3 North, used by residents #11, #131, and #190 was not functioning during an environmental review. The findings are: Resident #11 has [DIAGNOSES REDACTED]. The 4/12/17 Quarterly Minimum Data Set (MDS; a resident assessment tool) revealed that the resident had impaired cognition, and required extensive assistance of one person with activities of daily living (ADLs). Resident #131 has [DIAGNOSES REDACTED]. Resident #190 has [DIAGNOSES REDACTED]. The Significant Change MDS of 5/21/17 revealed that the resident had impaired cognition and required extensive assistance of one to two persons with ADLs. The above residents shared the same bathroom. A room observation was conducted 7/5/17 at 1:00 PM on 3 North Unit of the above residents' rooms and revealed that they are sharing the same bathroom. When the call bell was tested as part of environmental review, no sounds or lights were noted from the call bell system to alert the staff that the call bell had been activated. The other bathrooms were checked and had no problems with the call bells. The unit Licensed Practical Nurse (LPN) was interviewed on 7/5/17 at 1:05 PM, and stated that she was not aware of the call bell issue and for how long this problem had been going on. The LPN stated that she will notify the maintenance department. The Maintenance Director was interviewed on 7/5/17 at 3:30 PM and stated he was not aware of the above problem. A review of the Maintenance Log dated 6/3/17 to 7/11/17 did not reveal any documented evidence of any call bell issues in the above residents' rooms. A follow up observation of the same rooms was conducted on 7/10/17 at 1:52 PM with the same unit LPN and stated that the call bell system remained to be out of use. The LPN stated that the above residents can use the bathroom by themselves, except for Resident #190. The LPN further stated that residents #11 and #131 were given hand bells to use, following discovery by the surveyor, that the call bell system in the shared bathroom was not working. The Maintenance Director was interviewed again on 7/10/17 at 3:37 PM and stated that the call bell system was very old. The Maintenance Director stated that a representative from an outside company would be replacing the system and that hand bells were provided to the residents, following surveyor intervention. The Maintenance Director was interviewed further on 7/11/17 at 2:08 PM and stated that Maintenance Logs on each floor were checked daily by the assigned maintenance worker. He stated that he was not notified by the maintenance worker of any call bell issue. The Maintenance Director stated that the person who usually checks the maintenance logs was not available for interview. 415.29

Plan of Correction: ApprovedJuly 21, 2017

1 - On 7-5-17, the LPN immediately notified the maintenance Director of the malfunctioning call bell in the bathroom between room 320 and 321. The maintenance director provided a hand bell to resident #11 and #131. Resident #190 is unable to use the bathroom. On 7-5-17 The RN manager in serviced resident #11 and #131 on the use of the hand bell.
on 7-12-17 the call bell in the bathroom between room 320 and 321 was fixed and tested for function ability by a contracted vendor.
2- All residents have potential to be affected. On 7-5-17, the Administrator and Maintenance Director audited the call bells throughout the building. The ADNS/Inservice Educator will inservice all the direct care staff givers on checking the call bells and reporting it timely to maintenance department for those that malfuntion.
3- The Maintenance Director reviewed and revised the facilities log sheet. The Maintenance Director/designee will in service all the staff on the facilities revised maintenance log sheet and will emphasize the importance of logging any maintenance issues on the log sheet. The Maintenance staff will check the log sheet on each unit twice daily ; in the morning and the afternoon. Any maintenance issues that needs to be addressed immediately will be called in to the maintenance director/designee and will be logged into the maintenance log sheet.
4- The Maintenance Director reviewed and confirmed the audit tool on the call bell system. The maintenance staff will audit the call bells monthly. The QA will include testing of call bells in the rooms and direct observation. Any negative findings will be corrected immediately by the maintenance staff. The maintenance director will report the results to the QA committee at least quarterly. The maintenance director is responsible for compliance.

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

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 relocatable power taps were used in accordance with NFPA 99 and NFPA 70, National Electrical Code. Reference is made to the use of unapproved relocatable power taps, or inappropriate use of relocatable power taps in resident rooms, and relocatable power taps that were serially connected in the nursing office and telephone/computer area. This was noted on one of three resident floors and in the basement. The findings are: During the life safety recertification survey conducted on 7/8/17 and 7/10/17 between 11:00 AM and 2:30 PM, the following issues were noted: - At approximately 11:50 AM on 7/8/17, a tour of resident room [ROOM NUMBER] was conducted and it was noted that the resident's bed was plugged into a relocatable power tap with the UL listing E 3 model # . - At approximately 12:05 PM on 7/8/17, resident room [ROOM NUMBER] was toured and it was noted that the resident's lamp, clock and fish tank lamp were plugged into a relocatable power tap with the UL listing E 1 model # A 1582. - On 7/10/17 at approximately 11:40 AM, a tour of the basement was conducted and it was noted that relocatable power taps were daisy-chained or serially connected in the telephone and computer system area located adjacent to the nursing office. The power taps were energizing the computer system. In an interview at the time of the findings, the Director of Plant Operations stated that the manufacturers' specifications for the power taps observed in resident rooms are not on file. He further stated that he will contact the vendor to remove the daisy-chain of power taps in the telephone computer area. The Director of Plant Operations further stated that additional outlets will be installed in the nursing office. 2012 NFPA 101 2012 NFPA 99: 10.2.3.6, 10.2.4 2011 NFPA 70 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1- The facility engineering staff immediately removed unapproved power strips and the ?daisy chaining? of power strips from the following locations:
1. room [ROOM NUMBER]
2. room [ROOM NUMBER]
3. Computer/Telephone area adjacent to the Nurses Office
2- All areas throughout facility were checked for unapproved power strips and ?daisy chaining? of power strips. All such devices were immediately removed.
3- The Facilities Manager or Designee as part of environment of care rounds will begin conducting education to all staff to ensure the following are not in use:
1. Extension cords
2. Unapproved power strips
3. Power strips and/or extension cords installed in series
Any devices found during these rounds will be removed and staff re-educated.
4-The Facilities Manager or Designee will review weekly environment of care rounds for cases of:
1. Extension cords
2. Unapproved power strips
3. Power strips and/or extension cords installed in series
The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:ELECTRICAL SYSTEMS - MAINTENANCE AND TESTING

REGULATION: Electrical Systems - Maintenance and Testing Hospital-grade receptacles at patient bed locations and where deep sedation or general anesthesia is administered, are tested after initial installation, replacement or servicing. Additional testing is performed at intervals defined by documented performance data. Receptacles not listed as hospital-grade at these locations are tested at intervals not exceeding 12 months. Line isolation monitors (LIM), if installed, are tested at intervals of less than or equal to 1 month by actuating the LIM test switch per 6.3.2.6.3.6, which activates both visual and audible alarm. For LIM circuits with automated self-testing, this manual test is performed at intervals less than or equal to 12 months. LIM circuits are tested per 6.3.3.3.2 after any repair or renovation to the electric distribution system. Records are maintained of required tests and associated repairs or modifications, containing date, room or area tested, and results. 6.3.4 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

2012 NFPA 99 - 6.3.4.1 Maintenance and Testing of Electrical System. 6.3.4.1.3 Receptacles not listed as hospital-grade, at patient bed locations and in locations where deep sedation or general anesthesia is administered, shall be tested at intervals not exceeding 12 months. 6.3.4.2 Record Keeping. 6.3.4.2.1 General. 6.3.4.2.1.1 A record shall be maintained of the tests required by this chapter and associated repairs or modifications. Based on interview, and record review, the facility did not ensure that the electrical receptacles installed at patient bed locations were tested at intervals not exceeding 12 months, in accordance with NFPA 99. The findings are: On 7/8/17 at approximately 11:45 AM, the review of the facility's documentation was conducted. There was no documentation available for the last test of the electrical receptacles (outlets) installed in the resident rooms, or that these outlets are tested at intervals not exceeding 12 months. In an interview at the time of the findings, the Director of Plant Operations, stated that a preventative maintenance testing of the outlets in resident rooms was not conducted but that a checklist will be implemented. 2012 NFPA 99: 6.3.4.1.3, 6.3.4.2.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1 -The New Facilities Manager and the engineering staff will complete an inspection and testing of all electrical receptacles in resident bed locations. All results will be recorded in the NEW Records & Logs book. Any damaged or deficiencies of electrical receptacles will be immediately replaced.
2-The inspection and testing will be throughout the entire facilities resident bed locations. All results will be recorded in the NEW Records & Logs book. Any damaged or deficiencies of electrical receptacles will be immediately replaced.
3-The NEW Preventive Maintenance & Scheduling program will be followed reflecting the annual inspection and testing of Electrical Receptacles in Resident Bed locations throughout the facility.
All maintenance staff will receive additional education from the NEW Facilities Manager and all participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
4-The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

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: July 11, 2017
Corrected date: August 24, 2017

Citation Details

Based on observation and interview, the facility did not ensure that hazardous areas were separated from other spaces by smoke partition walls, ceilings, and doors in accordance with 8.4. This was evidenced by a door to a storage room that did not latch upon self-closing, and/or damaged smoke partition walls that would not resist the passage of smoke. The findings are: During the life safety tour conducted on 7/8/17 and 7/10/17 between the hours of 11:10 AM - 2:30 PM, the following issues were noted: - At approximately 12:40 PM on 7/8/17, the corridor door to the trash room located on the 3rd floor was tested and it did not latch upon self-closing. The door rested on the frame. - On 7/10/17 at approximately 10:25 AM, the 1st floor biohazard room was visited and a damaged sheet rock wall was noted behind the curtain in the room. Trash collection containers and red regulated medical waste containers were stored in the room. - At approximately 11:35 AM on 7/10/17, a tour of the elevator machine room in the basement revealed missing and damaged ceiling tiles in the room, exposing wiring and decking above. In an interview at the time of the findings, the Director of Plant Operations stated that the sheet rock walls and doors to the storage rooms are checked monthly. He further stated that the doors and walls to the storage rooms will be repaired and the missing or damaged ceiling tiles will be replaced. 2012 NFPA 101: 19.3.2.1, 8.4.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1 - The engineering staff immediately repaired the 3rd Floor Trash Room. The door does self-close and positive latch. The damaged wall in the 1st Floor Biohazard Room was immediately repaired. The damaged and missing ceiling tiles in the Basement Elevator Machine Room were immediately replaced.
2 - On 7-10-17 the engineering staff conducted an audit throughout the facility for hazardous areas doors for proper self-closers and positive latching. The engineering staff also checked the hazardous areas for damaged to walls and ceilings. Any identified deficiencies were completed that day.
3 - The NEW Preventive Maintenance & Scheduling program will be followed reflecting the daily and annual inspection of Doors to hazardous areas. The NEW Preventive Maintenance & Scheduling program will be followed reflecting the monthly check of all Hazardous rooms for wall/ceiling/floor integrity.
All maintenance staff will receive additional education from the NEW Facilities Manager and all participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
4- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:ILLUMINATION OF MEANS OF EGRESS

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

2012 LSC 101 7.8 Illumination of Means of Egress. 7.8.1.1 Illumination of means of egress shall be provided in accordance with Section 7.8 for every building and structure where required in Chapters 11 through 43. For the purposes of this requirement, exit access shall include only designated stairs, aisles, corridors, ramps, escalators and passageways leading to an exit. For the purposes of this requirement, exit discharge shall include only designated stairs, aisles, corridors, ramps, escalators, walkways, and exit passageways leading to a public way. 7.8.1.2 Illumination of means of egress shall be continuous during the time that the conditions of occupancy require that the means of egress be available for use, unless otherwise provided in 7.8.1.2.2 7.8.1.2.1 Artificial lighting shall be employed at such locations and for such periods of time as are necessary to maintain the illumination to the minimum criteria values herein specified. 7.8.1.3*The floors and other walking surfaces within an exit and within the portions of the exit access and exit discharge designated in 7.8.1 shall be illuminated as follows: (2) The minimum illumination for floors and walking surfaces, other than new stairs during conditions of stair use, shall be to values of at least 1 ft-candle (10.8 lux), measured at the floor. 7.8.1.4* Required illumination shall be arranged so that the failure of any single lighting unit does not result in an illumination level of less than 0.2 ft-candle (2.2 lux) in any designated area. Based on observation and interview, the facility did not ensure that the illumination of the means of egress on resident units was installed and maintained in accordance with 7.8. This was evidenced by manually operated wall-mounted switches installed on 4 of 4 resident units that, when turned to the off position, turned all of the lights off in the corridors; and the lack of sufficient illumination at the bottom landing of the North exit stairwell. This would not ensure that required and sufficient lighting would be continuously in operation and capable of automatic operation without manual intervention. The findings are: During the life safety tour conducted on 7/8/17 and 7/10/17 between the hours of 11:30 and 2:00 PM, manually operated wall mounted light switches were noted in the corridors on the resident sleeping floors. When these switches were manually turned to the off position, all lights in these corridors were turned off. In addition, a tour of the North exit stairwell was conducted at approximately 1:30 PM on 7/10/17, and it was noted that the bottom landing of the stairwell appeared dark, and lacked sufficient illumination for the emergency exit within the stairwell. This was noted in one of two stairwells. In an interview at the time of the findings, the Director of Operations stated that the wall mounted light switches will be changed. He further stated that the electrician will be contacted to ensure continuous illumination in the corridors, and that additional light will be installed near the bottom landing of the North stairwell. 2012 NFPA 101: 19.2.8, 7.8.1.1, 7.8.1.2.1, 7.8.1.4* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1 - ON 7-7-17, The facility engaged a licensed electrical contractor to permanently separate the Emergency lighting from the normal lighting on the identified 4 resident units. The licensed electrical contractor permanently removed the ability to switch the Emergency lighting on or off. The licensed electrical contractor will also permanently add sufficient light fixture(s) at the Bottom landing of the North Stairwell to provide at least the minimum candle power required by code.
1A- On 7-10-17 the engineering staff and the electrical contractor checked all areas throughout the facility for similar issues. No other areas were found.
2 -The established Preventive Maintenance & Scheduling program will be followed reflecting the monthly and annual inspection and testing of the emergency lighting throughout the facility.
3- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator
`

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: July 11, 2017
Corrected date: August 24, 2017

Citation Details

2012 NFPA 101: 7.2.1.9 Powered Door Leaf Operation. 7.2.1.9.1*General. Where means of egress door leaves are operated by power upon the approach of a person or are provided with power-assisted manual operation, the design shall be such that, in the event of power failure, the leaves open manually to allow egress travel or close when necessary to safeguard the means of egress. 7.2.1.9.1.3 A readily visible, durable sign in letters not less than 1 in. (25 mm) high on a contrasting background that reads as follows shall be located on the egress side of each door opening: IN EMERGENCY, PUSH TO OPEN Based on observation and staff interview, the power sliding doors at the main entrance were not in compliance with Chapter 7 in that two of two sets of sliding doors lacked the required signage, In an emergency, push to open. The findings are: During the life safety tour conducted on 7/10/17 at approximately 10:55 AM, it was noted that there were two sets of power sliding doors at the main entrance to the facility. These doors were not provided with the required sign indicating In Emergency, Push To Open. There was a small sticker on 1 of 2 sets of the sliding doors that stated push. This sticker was not on a readily noticeable part of the door. Upon request, the Director of Plant Operations was unable to demonstrate the break away feature of these doors once the automatic feature had been deactivated. In an interview at the time of the findings, the Director of Plant Operations could not provide an explanation. He further stated that the maintenance department would be notified if there were issues with the door. 2012 NFPA 101: 7.2.1.9.1, 7.2.1.9.1.3 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1- The Main entrance sliding doors were immediately posted with signage on each leaf, ?In Emergency, Push to Open? and permanent signage was ordered. The NEW Facilities Manager demonstrated how the breakaway feature of the sliding door operates and inspected and tested the operation successfully.
1a- There are no other doors with power assisted mechanisms in the facility.
2- The NEW Preventive Maintenance & Scheduling program will be followed reflecting the daily, quarterly and annual inspection and testing of the doors throughout the facility.
3- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

2012 NFPA 101 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7, unless otherwise permitted by 19.3.5.5 2013 NFPA 13 8.15.10 Electrical Equipment 8.15.10.1 Unless the requirements of 8.15.10.3 are met, sprinkler protection shall be required in electrical equipment rooms. 8.15.10.3 Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only (2) Only dry-type electrical equipment is used (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. Based on observation, it was determined that the facility did not ensure that electrical equipment rooms that lacked sprinklers were maintained free of combustible storage. Reference is made to combustible storage (cardboard boxes) in the electrical switch gear room located in the basement that lacked sprinkler coverage. The findings are: On 7/10/17 at approximately 11:20 AM, a tour of the electrical switch gear room was conducted and it was noted that two cardboard boxes containing computer modems were being stored in the room. The room lacked sprinkler coverage, and did not meet the exception for electrical equipment as per 8.15.10.3(4) of NFPA 13. In an interview at the time of the findings, the Director of Plant Operations stated that the electrical switch gear room was exempt from being sprinklered. 2012 NFPA 101: 19.3.5.1 2010 NFPA 13: 8.15.10 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1 - The engineering staff immediately removed the combustible storage from the Electrical Switch gear Room. The NEW Facilities Manager permanently affixed a sign at the door, ?NO STORAGE ALLOWED?.
2 - On 7-10-17_the engineering staff conducted an audit of Electrical Rooms/Closets. No storage was found. Electrical Rooms/Closets are only accessible to authorized personnel.
3- All authorized staff with access to Electrical Rooms/Closets will receive additional education from the NEW Facilities Manager and all participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
4- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 25 Chapter 5 Sprinkler Systems. 5.2.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage; and shall be installed in the correct orientation (e.g., upright, pendant, or sidewall). 2010 NFPA 13 Standard for the Installation of Sprinkler Systems 6.2.7 Escutcheons and Cover plates. 6.2.7.3 Cover plates used with concealed sprinklers shall be apart of the listed sprinkler assembly. 8.8.5.1.1 Sprinklers shall be located so as to minimize obstructions to discharge as defined in 8.8.5.2 and 8.8.5.3, or additional sprinklers shall be provided to ensure adequate coverage of the hazard. Based on observation, the facility did not ensure that automatic sprinkler heads installed in required areas were maintained in accordance with NFPA 25 and NFPA 13, as evidenced by: 1. Sprinkler heads exhibiting signs of corrosion (green discoloration), foreign material, oil and/or paint. 2. Sprinkler heads obstructed by ceiling tiles; and 3. Protective covers lacking for recessed sprinkler heads. The findings are: On 7/8/17 and 7/10/17 between the hours of 10:30 AM to 2:30 PM a life safety tour of the facility was conducted and the following issues with the sprinklers were noted: - At approximately 1:35 PM on 7/8/17, a tour of resident room [ROOM NUMBER] revealed that the protective cover for a recessed sprinkler head in the room was missing. - On 7/10/17 at approximately 10:45 AM, a tour of the 1st floor housekeeping closet revealed that the protective cover to the recessed sprinkler head in the room was obstructed by the ceiling tile. - On 7/10/17 at approximately 11:20 AM, a tour of the basement was conducted and the following was noted: - There was paint on all components of 3 of 3 sprinklers (head, frame and thread) in the women's locker room. - One of 2 sprinklers in the washer/dryer room within the laundry room was green (exhibited signs of corrosion) and coated with foreign material. - Paint and other foreign material was noted on 1 of 5 sprinklers in the service corridor. - Paint was noted on the deflector in the uniform storage room. - At approximately 12:10 PM on 7/10/17, a tour of the loading dock was conducted and oil and fire stop material was noted on one of two sprinklers in the elevator machine room located on the loading dock. In an interview at the time of the findings, the Director of Plant Operations stated that the sprinklers are checked monthly but not documented. He also stated that the sprinklers are checked quarterly by the vendor. 2012 NFPA 101 2011 NFPA 25: 5.2.1.1 2010 NFPA 13: 6.2.7.3, 8.8.5.1.1 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 31, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1- On 7-7-17, The facility engaged a licensed Sprinkler Company to replace, adjust, and provide protective covers to the following sprinkler pendants:
? room [ROOM NUMBER] ? provide and install missing protective cover
? 1st Floor Housekeeping Closet ? Adjust sprinkler pendant from obstructions
? Women?s Locker Room ? Replace sprinkler pendants
? Washer/Dryer Room in Laundry ? Replace sprinkler pendant
? Service Corridor ? Replace sprinkler pendant
? Uniform Storage Room ? Replace sprinkler pendant
? Elevator Machine Room on Loading Dock ? Replace sprinkler pendant
2- on 7-10-17 The facilities engineering staff completed the check of the entire facility to ensure all sprinklers were free from foreign material, had proper protective covers, and no obstructions.
3- The NEW Preventive Maintenance & Scheduling program will be followed reflecting the daily, weekly, monthly, quarterly, and annual inspection and testing of the sprinkler system throughout the facility.
4- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

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: July 11, 2017
Corrected date: August 24, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 713 -2.22 - Electrical requirements (f) The electrical circuit(s) to fixed or portable equipment in hydrotherapy units shall be provided with five milliampere ground fault interrupters. This requirement is not met as evidenced by: Based on observation and interview, the facility did not ensure that a ground fault circuit interrupter (GFCI) outlet was provided for the portable hydrotherapy unit ([MEDICATION NAME]) in the resident Rehab room. The findings are: On 7/10/17 at approximately 10:35 AM, the Rehab room was toured and it was noted that the portable hydrotherapy unit ([MEDICATION NAME]) was plugged into a relocatable power tap instead of the required GFCI outlet. This power tap was plugged into the standard electrical outlet. A GFCI outlet was noted on the adjacent wall, but the copy machine was plugged into that outlet. In an Interview at the time of the finding, the Director of Plant Operations stated that he believed that the hydrotherapy unit should be plugged into the GFCI outlet. 10 NYCRR 713-2.22 (f)

Plan of Correction: ApprovedAugust 1, 2017

1- On 7-10-17, the hydrotherapy unit was immediately unplugged from the power tap and plugged into a GFCI outlet. The power tap was removed from the room.
2- The rehab department was in-serviced on the requirement of plugging the hydrotherapy machine into a GFCI outlet only.
3- The maintenance staff ensured that no other units that required a GFCI outlet were plugged into a regular outlet in the facility.
4- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Construction 2012 EXISTING Smoke barriers shall be constructed to a 1/2-hour fire resistance rating per 8.5. Smoke barriers shall be permitted to terminate at an atrium wall. Smoke dampers are not required in duct penetrations in fully ducted HVAC systems where an approved sprinkler system is installed for smoke compartments adjacent to the smoke barrier. 19.3.7.3, 8.6.7.1(1) Describe any mechanical smoke control system in REMARKS.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

Based on observation, the facility did not ensure that smoke barriers were constructed to provide at least a one half hour fire resistance rating and were constructed in accordance with 8.3, in that a penetration was noted around the BX cable passing through the smoke barrier wall on 1 of 4 resident floors (4th floor), and the junction box installed above the ceiling tile in the same smoke barrier lacked the required protective cover. The findings are: During the life safety tour conducted on 7/10/17 at 2:30 PM, smoke barrier walls on the fourth floor were examined. In one of the two barrier walls examined, there was an opening around the BX cable that measured approximately a quarter of an inch in diameter and penetrated to the other side of the smoke barrier wall. In addition, a junction box installed above the suspended ceiling lacked a protective cover, exposing the wires for the smoke detector, nurse call system and lights. In an interview at the time of the findings, the Director of Plant Operations stated that he would immediately fill the penetrations noted around the BX cable, and that a protective cover for the junction box would be provided. 2012 NFPA 101: 19.3.7.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1- The facilities engineering staff immediately permanently sealed the penetration identified above the suspended ceiling on the 4th floor Smoke Barrier with approved fire stop material. The facilities engineering staff also permanently installed an electrical cover plate on the identified junction box above the suspended ceiling.
2- On 7-10-17 the engineering staff conducted an audit throughout the facility for penetrations in smoke barriers and opened electrical junction boxes. No other areas were found.
3- The NEW Preventive Maintenance & Scheduling program will be followed reflecting the semi-annual inspection of Fire and Smoke Barriers throughout the facility. The NEW Facilities Manager has instituted a policy that any contractor must fire stop any penetration immediately after the work has been completed or the end of the work day, whichever is first.
All maintenance staff will receive additional education from the NEW Facilities Manager and all participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
4- The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 11, 2017
Corrected date: August 24, 2017

Citation Details

19.3.1 Protection of Vertical Openings. Any vertical opening shall be enclosed or protected in accordance with Section 8.6, unless otherwise modified by 19.3.1.1 through 19.3.1.8 19.3.1.1 Where enclosure is provided, the construction shall have not less than a 1-hour fire resistance rating. 8.6 Vertical Openings 8.6.1 Floor smoke barriers. Every floor that separates stories in the building shall meet the following criteria: (1) It shall be constructed as a smoke barrier in accordance with 8.5 (2) It shall be permitted to have openings as described by 8.6.6, 8.6.7, 8.6.8,8.6.9 Based on observation and staff interview, it was determined that all floors separating stories in the building were constructed as smoke barriers in accordance with 8.6, as evidenced by an opening in the floor of the 2nd floor housekeeping closet that penetrated the ceiling of the 1st floor housekeeping closet below. The findings are: On 7/8/17 at approximately 1:20 PM, a tour of the housekeeping closet on the second floor was conducted and an opening was observed in the floor that penetrated to the floor below. A BX cable, air conditioner pipe, PVC pipe and the conduit pipes to the electrical panel in the room ran through the opening, which measured approximately 3 and 1/2 inches in circumference. The housekeeping closet on the 1st floor below was toured and an opening was noted in the ceiling tiles around the pipes in the room. In an interview at the time of the finding, the Director of Plant Operations stated that the floor of the 2nd floor housekeeping closet will be sealed. 2012 NFPA 101: 19.3.1, 8.6 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJuly 31, 2017

1- ON 7-7-17, The facility contacted its engineering staff to immediately seal the penetrations identified in the ceiling of the 1st and 2nd Floor Housekeeping Closet with approved fire stop material.
1a - An outside vendor was called to reseal the floor and ceiling of the 2nd and 1st hk closet.
2- On 7-10-17 the engineering staff conducted an audit throughout the facility for penetrations in ceilings/floors requiring a fire rated partition. No other areas were found.
3- The NEW Preventive Maintenance & Scheduling program will be followed reflecting the semi-annual inspection of Fire and Smoke Barriers throughout the facility. The NEW Facilities Manager has instituted a policy that any contractor must fire stop any penetration immediately after the work has been completed or the end of the work day, whichever is first. All maintenance staff will receive additional education from the NEW Facilities Manager and all participants will understand the life safety issues identified during the facility?s survey and the importance of ensuring compliance with the identified life safety issues on a routine basis.
4 - The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator