Alpine Rehabilitation and Nursing Center
June 14, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.20(f)(1)-(4):ENCODING/TRANSMITTING RESIDENT ASSESSMENTS

REGULATION: §483.20(f) Automated data processing requirement- §483.20(f)(1) Encoding data. Within 7 days after a facility completes a resident's assessment, a facility must encode the following information for each resident in the facility: (i) Admission assessment. (ii) Annual assessment updates. (iii) Significant change in status assessments. (iv) Quarterly review assessments. (v) A subset of items upon a resident's transfer, reentry, discharge, and death. (vi) Background (face-sheet) information, if there is no admission assessment. §483.20(f)(2) Transmitting data. Within 7 days after a facility completes a resident's assessment, a facility must be capable of transmitting to the CMS System information for each resident contained in the MDS in a format that conforms to standard record layouts and data dictionaries, and that passes standardized edits defined by CMS and the State. §483.20(f)(3) Transmittal requirements. Within 14 days after a facility completes a resident's assessment, a facility must electronically transmit encoded, accurate, and complete MDS data to the CMS System, including the following: (i)Admission assessment. (ii) Annual assessment. (iii) Significant change in status assessment. (iv) Significant correction of prior full assessment. (v) Significant correction of prior quarterly assessment. (vi) Quarterly review. (vii) A subset of items upon a resident's transfer, reentry, discharge, and death. (viii) Background (face-sheet) information, for an initial transmission of MDS data on resident that does not have an admission assessment. §483.20(f)(4) Data format. The facility must transmit data in the format specified by CMS or, for a State which has an alternate RAI approved by CMS, in the format specified by the State and approved by CMS.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 15, 2018
Corrected date: August 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification survey, the facility did not complete Minimum Data Set (MDS) assessments or submissions for 5 of 8 residents (Residents #2, 4, 6, 7 and 8) as required by the Centers for Medicare and Medicaid Services. Specifically, Residents #4, 6, 7 and 8 did not have discharge assessments completed and Resident #2 did not have an OBRA (Omnibus Budget Reconciliation Act) assessment submitted. Findings include: 1) Resident #4 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The [DATE] quarterly Minimum Data Set Assessment (MDS) documented the resident was moderately cognitively impaired and he required total dependence for activities of daily living (ADLs). There was no documentation that a discharge MDS had been completed following this date. A [DATE] social services progress note documented the resident was discharged to home this date. During an interview with MDS Coordinator #7 on [DATE] at 10:15 AM, she stated residents that were discharged required a discharge MDS and she was not sure why the resident's MDS was not completed and must have been missed. 2) Resident #6 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. There was no documentation that a death in facility MDS had been completed following this date. A [DATE] at 04:54 AM nursing progress note documented the resident expired at 02:30 AM. During an interview with MDS Coordinator #7 on [DATE] at 10:15 AM, she stated residents that expired at the facility were required to have a death in facility MDS and the resident's assessment may have been overlooked. 3) Resident #2 was admitted on [DATE] and had a [DIAGNOSES REDACTED]. The [DATE] discharge Minimum Data Set (MDS) assessment documented the resident was independent with decision making and required extensive assistance with activities of daily living (ADLs). The MDS did not document that it had been submitted to the Centers for Medicare and Medicaid Services. The resident's demographic information documented the resident Medicare and HMO (Health Maintenance Organization) insurance and did not have Medicaid. A [DATE] social services progress note documented the resident was admitted to the facility for short term rehabilitation following a hospitalization . During an interview with MDS Coordinator #7 on [DATE] at 10:15 AM, she stated the resident had an HMO plan and she did not think that the assessments needed to be submitted. 10 NYCRR 415.11

Plan of Correction: ApprovedJuly 9, 2018

1. The following corrective actions were accomplished for the residents found to have been affected by not having required MDS assessments or submissions completed as required by the Centers for Medicare and Medicaid Services.
Resident # 4, 6,7,8 - Discharge assessments have been completed for each of these residents and submitted to the CMS System.
Resident #2 ? OBRA assessment has been completed and submitted as required to the Centers for Medicare and Medicaid Services.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if required MDS assessments and submissions are not completed and submitted as required by the Centers for Medicare and Medicaid Services. Qies, Casper and MDS software reports are being monitored for missing MDS assessments and for residents that are discharged or deceased who may still show as active on the Casper report. Each resident?s MDS history is being reviewed to ensure there are no other missing OBRA assessments or other required assessments, including those required for discharge and death. In addition, it is being checked that all required MDS assessments have been submitted.
3. The following systems changes will be implemented to assure continuing compliance with timely and appropriately submitted MDS assessments.
The MDS policy and procedure has been reviewed to ensure time frames for completion and submission are indicated appropriately.
Each resident?s MDS history will be reviewed each month during the last week of the month to ensure all OBRA assessments have been completed and submitted as required. The resident census list, MDS schedule and MDS computer program will be used to determine any assessments due for the next month.
At the beginning of each week census for the previous 7 days will be reviewed at morning meeting with MDS coordinator and Administration for any resident discharges or deaths. As MDS coordinator completes and submits required MDS for deaths or discharges a report will be provided to Administrator via email.
The monthly printed Casper reports will be reviewed each month to determine if there are any discharged or deceased residents that have not had a discharge assessment completed and submitted within the proper time frame as required by regulation.
4. Facility?s compliance will be monitored utilizing the following quality assurance system.
A monthly audit will be given to the QAPI committee of any missing OBRA required assessments found and correction dates until 100% compliance for three months.
Each week a report will be given to the Administrator of discharge or death MDS required assessments completed and submitted along with census information including date of discharge or death. Those reports will be presented to the QAPI committee. Reports will be submitted each week until two months of 100% compliance of timely MDS completion and submission.

Responsible Party: MDS Coordinator

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: §483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. §483.80(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: §483.80(a)(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; §483.80(a)(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. §483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. §483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. §483.80(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: June 15, 2018
Corrected date: August 1, 2018

Citation Details

Based on record review and interview conducted during the recertification survey, the facility did not ensure and maintain an infection prevention and control program to provide a safe, sanitary, and comfortable environment to help prevent the development and transmission of communicable disease and infections. Specifically, facility was not maintaining the washing machines and dryers according to manufacturers recommendations (weren't documenting weekly/monthly/quarterly report inspections). Findings include: The manufacturer instructions for the facility washing machines documented to inspect monthly or every 200 hours of operation: - V-belts for determination of replacement or adjustment; - hoses for leaks; - inlet screens; - motor mounting bolts; - lint; - interior of washer-extractor; and - electrical components. The manufacturer instructions for the facility washing machines documented to inspect quarterly: - door hinges and fasteners; - anchor bolts; - drain motor shield; - painted surfaces for bare metal; and - clean steam filter. The manufacturer instructions for the facility tumble dryers documented to inspect monthly: - electrical connections; - electrical controls; - lint filter and exhaust duct; - fan; - wash lint screen; - inspect door assembly; - inspect steam coil air intake filter; and - inlet hoses if equipped with a fire suppression system. The manufacturer instructions for the facility documented to inspect yearly and remove lint if applicable: - front panel and cylinder; - seals, rollers, bearings, idler assembly, drive pulley and belt; - thermistor and thermostats; - drive, blower motors, burner tubes, orifice area; - steam coils and/or heat exchange kit; - exhaust ducts; - burners for gas models; - hardware; - guards and panels; - painted surfaces for bare metal; - run a factory test; and - replace belts and fire suppression water inlet hoses every 5 years. On 6/14/2018 at 1:07 PM, the Director of Maintenance stated the facility did not have any completed maintenance log/records to verify that the manufacturer requirements were being followed. He stated he was aware of what needed to be done and at what time frame but it was not documented. He stated he did follow manufacturer guidelines, and had copies of paperwork. There were no provided records the washing machine or dryer inspections were being done. 10 NYCRR 415.29 (k)

Plan of Correction: ApprovedJuly 11, 2018

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were cited.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if laundry washing machine and dryer maintenance, according to manufactures recommendations, is not being documented. It is necessary for personnel to handle, store, process and transport linens so as to prevent the spread of infection. Using manufacturer recommendations, forms were developed to document maintenance checks and actions required for specific time frames, forms have been put into use as stated below.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
The facility policy and procedure, Routine and Preventative Maintenance, was reviewed and revised adding laundry washer and dryer recommended daily, weekly, monthly, quarterly and annual maintenance checks and actions.
Forms were developed to document maintenance checks and actions completed for each timeframe as above. Forms are to be kept in the Patient Related Electrical Equipment binder as stated in the revised policy, Routine and Preventative Maintenance.
New forms are now being utilized for daily, weekly, monthly, quarterly and annual maintenance checks and actions per manufacturer recommendations for laundry washers and dryers. All maintenance checks and actions including annual and quarterly will be conducted and documented before the completion date of this correction to ensure a proper starting point for documentation and to start the calendar for manufacturer recommendations.
Education will be provided regarding the performance and documentation of daily and weekly maintenance or safety checks and other actions recommended for laundry washers and dryers that will be the responsibility of the laundry staff, to all staff that work or may work in the laundry. Environmental Services/maintenance staff will be provided with education regarding performance of and documentation regarding all recommended maintenance and other actions daily, weekly, monthly, quarterly and annual
4. Facility?s compliance will be monitored utilizing the following quality assurance system.
Copies of newly developed and completed maintenance checks and actions forms that document manufacturer recommendations will be presented to the QAPI committee for daily, weekly and monthly maintenance actions, monthly for two months. Quarterly and Annual forms will be presented to the QAPI committee at the next meeting after completion. Quarterly forms will be presented to the committee for two quarters.

Responsible Party: Director of Environmental Services

FF11 483.90(i)(4):MAINTAINS EFFECTIVE PEST CONTROL PROGRAM

REGULATION: §483.90(i)(4) Maintain an effective pest control program so that the facility is free of pests and rodents.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 15, 2018
Corrected date: August 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview conducted during the recertification survey, the facility did not maintain an effective pest control program for 2 of 2 units (South Unit, and North Unit) and two isolated rooms (kitchen and South Unit main shower/tub room). Specifically, pest control was not maintained for small black flies for the above mentioned rooms. Findings include: Surveyor observations on 06/12/18 included: - Between 07:06 PM and 07:12 PM, a surveyor observed multiple fruit flies, 50 to over 100, in the kitchen. They were mostly confined to the dishwasher area. The tile floor by the dishwash area drain was damaged and the water would not flow to the drain. There were two towels soaking up water at the time of the observation. Both of the handwash sinks in the kitchen were damaged and loose from the wall, and there were addition broken wall tiles in that area. Surveyor observations on 06/13/18 included: - At 09:56 AM, four fruit flies in the South Unit main shower/tub room. - At 09:56 AM, one fruit fly on the ceiling in the hall near the North Unit nursing station. - At 04:30 PM, a fruit fly on the ceiling in the hall near room [ROOM NUMBER]. - At 06:00 PM, there were over 60 fruit flies in the kitchen near the dishwash area. The wall surrounding the dishwash area was soiled/dirty, the edges along the floor/wall had debris, and the area around the drain had debris. During this observation the Food Service Director stated she had been seeing fruit flies last week. On 06/14/18 at 11:30 AM, a surveyor observed 10 fruit flies on the walls/ceiling of the main dining room. There were over 20 in the dishwash area of the kitchen, and 3 fruit flies on the ceiling near the South Unit nursing station. Record review on 6/13/2018 of the outside pest control service reports revealed, from 03/2018-05/2018, there were sightings of fungus gnats located in the food storage/receiving areas, the product preparation/receiving areas, and the kitchen dishwashing areas. The report did not indicate if the South Unit and North Unit were inspected/treated within this time frame. During an interview with licensed practical nurse (LPN) #2 on 06/15/18 at 08:55 AM, she stated she saw a couple of fruit flies a few weekends ago flying around the applesauce on her medication cart. She stated she would notify maintenance if she saw a larger number of fruit flies, and would not notify and did not notify for the 1-2 she saw on her medication cart. During an interview with the Director of Maintenance on 06/15/18 at 09:10 AM, he stated that the outside pest control company manages their pest control at the facility. That company would come weekly and survey the entire building including outside the building. He stated there have been no recent issues with fruit flies and believed the company treated the kitchen area but did not recall the date. He stated there was a book with the company's reports and he would have to look there. The company would print the report before they left the building and placed it in the book. He stated he rarely read the reports as he was busy with other tasks and the reports were difficult to read because they printed in a ribbon fashion and had to be unfolded to be read. 10 NYCRR 415.29(j)(5)

Plan of Correction: ApprovedJuly 9, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents have been cited.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if an effective pest control program is not maintained. The facility?s pest control provider was asked to come to the facility to assess and treat areas identified as having fruit flies. The pest control provider was able to come to the facility the next day to assess and treat the drains in the kitchen, including dishwashing area and south main shower/tub room. Results were effective.
Hand washing sinks in the kitchen were repaired and broken, wall tiles are being repaired or replaced. Dish washing area was cleaned. Drain area is being repaired to allow proper water flow to the drain.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
After information was gathered from pest control provider and kitchen supply company it was decided to have the kitchen supply company install an injection system in the dish room drain (primary source of drain flies) to automatically inject into the drain daily at the end of the kitchen?s work day an enzyme sewer treatment that will prevent drain flies. Additionally the pest control provider is treating floor drains with a foam chemical to help prevent drain flies at least monthly. They will treat more often if there are reports of drain flies.
The south and north side shower rooms and other kitchen drains will be treated with the Enzyme treatment monthly. The treatment will be added to the shower deep cleaning schedule and in addition the housekeeping staff will be instructed to watch for any signs of drain flies. Specific drain fly education will be provided to the housekeeping staff and kitchen staff. If there are any further signs of drain flies the treatments for those areas will be increased to weekly.
Education will be provided to facility staff to report any insect or pest issue immediately to Maintenance and/or Administrator in order to better direct the pest control company on needed service. Reports by staff will be documented in the maintenance books by either staff or maintenance for tracking purposes.
4. Facility?s compliance will be monitored utilizing the following quality assurance system.
Copy of pest control provider reports after each visit indicating treatment for [REDACTED].
Environmental services will audit drain areas weekly for any sign of drain flies, copies of those audits will be turned into the Administrator for inclusion in the QAPI committee meeting. Audits will continue weekly for at least two months or until at least 4 weeks with no drain flies.

Audits of cleanliness of dish room area after dishwashing is completed will be conducted daily for two weeks and then weekly and audit results will be given to the QAPI committee. Weekly audits will be ongoing for three months or until compliance is 95%.
Responsible Party: Director of Environmental Services

FF11 483.10(g)(14)(i)-(iv)(15):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC.)

REGULATION: §483.10(g)(14) Notification of Changes. (i) A facility must immediately inform the resident; consult with the resident's physician; and notify, consistent with his or her authority, the resident representative(s) when there is- (A) An accident involving the resident which results in injury and has the potential for requiring physician intervention; (B) A significant change in the resident's physical, mental, or psychosocial status (that is, a deterioration in health, mental, or psychosocial status in either life-threatening conditions or clinical complications); (C) A need to alter treatment significantly (that is, a need to discontinue an existing form of treatment due to adverse consequences, or to commence a new form of treatment); or (D) A decision to transfer or discharge the resident from the facility as specified in §483.15(c)(1)(ii). (ii) When making notification under paragraph (g)(14)(i) of this section, the facility must ensure that all pertinent information specified in §483.15(c)(2) is available and provided upon request to the physician. (iii) The facility must also promptly notify the resident and the resident representative, if any, when there is- (A) A change in room or roommate assignment as specified in §483.10(e)(6); or (B) A change in resident rights under Federal or State law or regulations as specified in paragraph (e)(10) of this section. (iv) The facility must record and periodically update the address (mailing and email) and phone number of the resident representative(s). §483.10(g)(15) Admission to a composite distinct part. A facility that is a composite distinct part (as defined in §483.5) must disclose in its admission agreement its physical configuration, including the various locations that comprise the composite distinct part, and must specify the policies that apply to room changes between its different locations under §483.15(c)(9).

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 15, 2018
Corrected date: August 1, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during the recertification and abbreviated surveys (NY 547) the facility did not ensure the family representative was notified of a change in the resident's condition for 1 of 4 residents (Resident #283) reviewed for pressure ulcers/injuries. Specifically, Resident #283's representative was not notified timely regarding a change in the resident's skin condition. Findings include: The 10/23/07 updated facility's Resident Accident/Incident policy documented staff were to notify family/designated representative. The policy did not specify a time period. Resident #283 was admitted on [DATE] and had [DIAGNOSES REDACTED]. The 11/06/16 Minimum Data Set (MDS) assessment documented the resident had severely impaired cognition, required extensive assistance with most activities of daily living (ADLs) to include transfer, bed mobility, and toileting. The MDS documented the resident had no open areas, was at risk for developing pressure ulcers, had pressure reducing devices for her bed and chair, and had no restraints. The 07/09/16, 08/17/16, and 11/14/16 pressure ulcer risk assessments documented the resident was a high risk for developing pressure ulcers. The 09/15/16 comprehensive care plan (CCP) documented the resident was a risk for pressure ulcers. Interventions included assess skin every shift, avoid pressure over bony prominences, reposition and toilet every 2-3 hours, moisture barriers for peri care, elevate heels in bed and protect heels out of bed, and pressure reduction surfaces in wheelchair and bed. The 11/08/16 at 10:32 AM progress note documented during wound rounds the resident's second digit right foot had an unstageable red scabbed wound measuring 1.0 x 0.7 centimeters (cm) and the licensed practical nurse (LPN) would advise the physician on new findings and provide heel floats for wound maintenance. The 11/11/16 weekly pressure injury flow sheet documented the resident had a new 5.0 x 5.5 cm Stage II pressure ulcer on her right heel, skin prep was the treatment, and heel booties with no shoes was the pressure relieving devices. Nursing progress notes documented: - On 11/11/16 at 12:02 PM, a 5.0 x 5.5 cm intact blister noted on the right heel Stage II. Skin prep was ordered. Heel floats for off loading were placed on the resident. - On 11/11/16 at 03:53 PM, the resident complained of right heel pain when trying to ambulate. A large intact blister noted, skin prep applied, and the RN Unit Manager and social worker were made aware. - On 11/15/16 at 03:49 PM, the right heel instep had a large clear fluid filled blister measuring 8.0 x 7.5 cm and heel floats were intact - On 11/15/16 at 05:55 PM, the resident was at the hospital for a fracture. The 11/15/16 weekly pressure injury flow sheet documented the resident had a clear fluid filled blister on her right instep that measured 8.0 x 7.5 cm, and skin prep was the treatment. There was no documented evidence the facility informed the family the resident had acquired a pressure ulcer either on her heel. When interviewed on 06/14/18 at 03:35 PM, the resident's family member the resident had a sore that developed on her heel that was not brought to family's attention until she went to the hospital. He stated the facility never contacted family about the sore on her heel, and the heel pressure ulcer was horrible when he saw it in the hospital. When interviewed on 06/15/18 at 11:22 AM, registered nurse (RN) Unit Manager #3 stated if a resident had any open skin areas or pressure ulcers, she expected it to be reported and documented on skin sheets, progress notes, and on the admission assessments. Family were to be notified of falls or injuries within 24 hours of occurrence by a nurse. When interviewed on 06/15/18 at 12:27 PM, the Director of Nursing (DON) stated she expected staff to notify family of falls within 24 hours, and within a week for pressure ulcers depending on when the resident was seen by the wound physician. The wound physician was in the facility once a week. She expected the notification to be done by RNs or LPNs, and documented in the CCP or nurse progress notes. When re-interviewed on 06/15/18 at 12:47 PM, RN Unit Manager #3 stated she felt the family should have been notified the resident had a pressure ulcer by the next day post discovery, and the facility had no specific time frame of notification. If the family was notified it would have been documented in the progress note, and a RN should be the one to tell them. She stated she was not sure if she told the family, as there was no documentation of it, and she was not sure why. She stated it should have been documented if she told them. When re-interviewed on 06/15/18 at 1:45 PM, the DON stated the facility had no family notification specific policy, and family notification was incorporated into the Accident/Incident policy. 10 NYCRR 415.3(e)(2)(ii)(d)

Plan of Correction: ApprovedJuly 11, 2018

1. The following corrective actions were accomplished for the residents found to have been affected.
Resident #283 ? This resident no longer resides at this facility.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected if resident?s family or other resident representatives are not informed or not informed timely of a resident?s change in condition, and specifically, if a resident has a change in skin condition. Care plan team has discussed need for a new policy regarding notification of resident changes. Licensed staff and Department directors will receive in-service regarding the new policy.
Residents with current skin issues will be reviewed to be sure families are aware and that notification or conversations are documented in the resident medical record.
3. The following systems changes will be implemented to assure continuing compliance with regulations.
Notification of Resident Changes policy is being developed, that will be specific regarding timeframes and circumstance. It will include specifics regarding changes in skin condition. Time frames for notification of resident changes have been standardized as much as possible to avoid confusion. Documentation of notification of resident changes in the medical record will be addressed in the new policy to include timing of what, when, who was called and by whom.
4. Facility?s compliance will be monitored utilizing the following quality assurance system.
Audits will be conducted of notification of changes reported to resident family or other resident representative of any skin changes on a weekly basis until 100% compliance for 4 weeks. Report will be given to team at Friday morning meeting of the previous 7 days and to the QAPI committee.
Responsible Party: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 14, 2018
Corrected date: July 20, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure the building was protected throughout by an approved automatic sprinkler system for 1 isolated room (fan room/record storage room) in accordance with National Fire Protection Association (NFPA) 13 - Standard for Installation of Sprinkler Systems section 8.3.3.2. Section 8.3.3.2 states: Where quick response sprinklers are installed, all sprinklers within a compartment shall be quick response unless otherwise permitted in 8.3.3.3. Specifically, the fan room/record storage room contained both quick response and standard response sprinkler heads. Findings include: On 06/13/18 at 11:08 AM, a surveyor observed the fan room/record storage room contained 3 quick response sprinkler heads and 6 standard response sprinkler heads. During an interview with the Director of Maintenance on 06/13/18 at 11:08 AM he stated he was not aware that single smoke compartments/rooms could not have mixed standard and quick response sprinkler heads. 2012 NFPA 101: 19.3.5.1, 9.7.1.1 2010 NFPA 13: 8.3.3.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJune 30, 2018

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified.
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected by having mixed quick response and standard sprinkler heads in the same compartment. The Environmental Services staff contacted the facility?s contracted sprinkler maintenance company, (NAME)son Controls, on 6/14/2018 to inquire about having the six standard sprinkler heads in the fan/records room replaced. A sprinkler installer from the contracted sprinkler maintenance company arrived onsite on 6/14/2018 in the afternoon to inspect the fan/records room sprinkler heads to get information to develop a quote to have the six standard sprinkler heads replaced. Quote was received and approved and the work to have the standard sprinkler heads replaced with quick response sprinkler heads will be conducted before 7/20/2018.
3. Measures or systemic changes made to ensure mixed quick response and standard sprinkler heads installed in the same compartment does not recur.
The Environmental services staff will perform a full facility audit of the sprinkler heads to help determine if there are any other areas in the building that have mixed type sprinkler heads. If other areas are found to have mixed type sprinkler heads the contracted sprinkler company will be notified of the need for further work to ensure compartments have the same type sprinkler heads. If needed the work will be scheduled immediately to correct. The Environmental services staff will also perform an inspection after any repair or maintenance that is completed by the contracted sprinkler maintenance company to make sure the sprinkler heads are not mixed types in a compartment.
4. The Facility?s corrective actions to prevent recurrence will be monitored utilizing the following quality assurance system.
A written report will be given to the facility?s QAPI committee upon completion of the full facility inspection of the sprinkler heads. A written report will be given to facility?s QAPI committee upon completion of the replacement of the standard sprinkler heads with quick response sprinkler heads to ensure the facility?s sprinkler heads are not mixed in a compartment. If any future repair or maintenance is performed on the facility?s sprinkler system, a written report documenting the inspection of the sprinkler heads will be given to the facility?s QAPI committee to ensure the sprinkler heads are of the same type in a compartment.
Responsible Party: Director of Environmental Services

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: June 14, 2018
Corrected date: July 20, 2018

Citation Details

Based on observation and interview conducted during the recertification survey, the facility did not ensure that all vertical openings were properly enclosed with construction having a fire resistance rating of at least one hour for 1 isolated area (the South unit storage room). Specifically, the South unit storage room floor had an unsealed vertical penetration to the floor below. Findings include: On 06/13/18 at 11:29 AM in the south unit storage room a surveyor observed a 3 inch hole in the floor that was not sealed. There was a 1 inch pipe passing through to the floor below. During an interview on 06/13/18 at 11:29 AM with the Director of Maintenance, he stated he did not know there was a penetration in that area. 2012 NFPA 101: 19.3.1, 8.6.2 10 NYCRR 415.29(a)(2), 711.2(a)(1)

Plan of Correction: ApprovedJune 30, 2018

1. The following corrective actions were accomplished for the residents found to have been affected.
No specific residents were identified. All residents have the potential to be affected if vertical penetrations are not properly enclosed or sealed. The vertical penetration in the South storage room was sealed on 6/13/2018 with approved fire rated material, (fire rated caulk).
2. Other residents that have the potential to be affected have been identified and the following corrective actions will be implemented to be sure residents are not affected by the same practice:
All residents have the potential to be affected. The Environmental Services staff performed an entire building audit on 6/18/2018 to check for any other vertical penetrations that were not properly sealed. The building is one story with a partial basement. The Environmental Services staff performed this audit from both the basement and from above on the first floor to better identify areas that were not previously observed. This audit included physically and visually checking around pipes and other items that penetrate the floor by touching, shaking, and investigating the materials that are currently sealing vertical penetrations to ensure they are correctly sealed with approved fire rate materials. No other open or improperly sealed vertical penetrations were discovered during this audit.
3. The following measures will be put in place or systemic changes will be implemented to ensure compliance with regulations.
The following systems changes will be implemented to ensure there are no open or improperly filled vertical penetrations in the fire rated barrier between floors. Inspections of the fire rated barrier between the basement area and the first floor will be added to the currently existing smoke barrier audit that is completed and documented annually. Inspections of the smoke compartments on first floor and partial basement fire rated barrier floor will also be conducted and documented if at any time there are repairs, maintenance, or construction in the facility that would require objects to penetrate the smoke barrier or fire barrier between the basement and the first floor.
4. Corrective actions will be monitored to ensure there will be no recurrence of open vertical penetrations of the fire rated barrier. Compliance with monitoring this corrective action will be maintained with the following quality assurance system:
The Environmental Service staff will add the examination of pipes and other equipment that may go between the first floor and basement to the existing smoke compartment and fire rated barrier audit that is conducted annually. A written report of the audit of 6/18/2018 will be given to the facility?s QAPI committee. A written report will also be given to the facility?s QAPI committee of future annual audits, and if at any time there are repairs, maintenance, or construction that occurs in the facility where objects penetrate the fire rated barrier between the basement and the first floor.
5. Responsible Party: Director of Environmental Services