East Haven Nursing & Rehabilitation Center
January 10, 2017 Certification Survey

Standard Health Citations

FF10 483.10(a)(1):DIGNITY AND RESPECT OF INDIVIDUALITY

REGULATION: (a)(1) A facility must treat and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life recognizing each resident?s individuality. The facility must protect and promote the rights of the resident.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

Based on observations and interviews conducted during a recertification survey, the facility did not ensure that residents in 4 of 4 units were provided sanitary and dignified dining experience during lunch meals. Specifically, plastic plate covers were placed on tables and were used to collect various garbage as residents eat their meals. Furthermore, this situation added to the limited amount of space for the residents to eat on the dining table. The findings are: Lunch meal observations were conducted on 4 of 4 dining rooms, on 1/4/17 to 1/6/17. It was noted that plastic plate covers for each of the residents' plates were upturned and placed on the tables as residents ate their food. The upturned plate covers were then filled with discarded debris such as napkins, paper wrappers, plastic covers and other items from the residents' trays. This situation added to the limited amount of space for each resident while he/she ate lunch. The unit Licensed Practical Nurse (LPN #4) and Registered Dietitian on the 4th floor dining room were interviewed on 01/09/17 at 12:20 PM and stated they don't know why these plate covers needed to be left on the tables while residents ate their meals. The unit LPN #1 on the 1st floor dining room was interviewed on 01/09/17 at 12:30 PM and stated she did not know why the plate covers were left left on the residents' table and why they couldn't be placed on a rack while residents eat their meals. The unit LPN on the 3rd floor (LPN #5) dining room was interviewed on 1/9/17 at 12:35 PM and was asked why was there were discarded debris from residents' trays in the upturned plate covers. LPN #5 stated the plate covers should have been removed from the tables and garbage placed in the garbage bin. 415.5(a)

Plan of Correction: ApprovedJanuary 26, 2017

F241
I. Immediate Corrections
1. The DNS provided educational counseling to LPN #1, #4, and #5 for failing to ensure that the residents received meals in full recognition of their dignity, and in compliance with infection control and sanitation. A copy of the counseling was filed for reference and validation.
2. The Administrator, Director of Nursing, and the Registered Dietician reviewed the facility policy and procedure on Resident Dining, dignity, infection control, and sanitation and the proper method of disposing of refuse and found same to be compliant.
3. All licensed and certified nursing staff, dietary aides, recreation staff, and ancillary staff assisting with the meal pass will be inserviced by the Director of Nursing on dignity relative to the residents? dining experience, infection control, and sanitation. The lesson plan will concentrate on the following:
a. Review of the intent and interpretive guidelines for F241 Dignity;
b. Review of the intent and interpretive guidelines for F371 Food Service and Sanitation;
c. Review of the facility policy and procedure on Resident Dining dignity, infection control, and sanitation and the proper method of disposing of refuse
d. The lesson plan and attendance will be filed for validation.
4. All residents currently receive meals in full recognition of their dignity and in compliance with facility policy on infection control, and sanitation and the proper method of disposing of refuse during the meal pass.
II. Identification of Other Residents
1. The facility respectfully submits that all residents who eat their meals on the units were potentially affected by the deficient practice.
III. Systemic Changes
1. The Administrator, Director of Nursing, and the Registered Dietician reviewed the facility policy and procedure on Resident Dining, dignity, infection control, and sanitation and the proper method of disposing of refuse and found same to be compliant.
2. All licensed and certified nursing staff, dietary aides, recreation staff, and ancillary staff assisting with the meal pass will be in serviced by the Director of Nursing/Designee on dignity relative to the residents? dining experience, infection control, and sanitation. The lesson plan will concentrate on the following:
a. Review of the intent and interpretive guidelines for F241 Dignity;
b. Review of the intent and interpretive guidelines for F371 Food Service and Sanitation;
c. Review of the facility policy and procedure on Resident Dining dignity, infection control, and sanitation and the proper method of disposing of refuse
d. The lesson plan and attendance will be filed for validation.
3. All residents currently receive meals in full recognition of their dignity and in compliance with facility policy on infection control, and sanitation and the proper method of disposing of refuse during the meal pass

IV. QA Monitoring
1. The Director of Nursing and Registered Dietician developed an audit tool to monitor the dignity, infection control, and sanitation during Resident dining.
2. Audits will be done by the DNS/designee on all units weekly for the first quarter, and then quarterly and at random thereafter.
3. Audits with negative findings will have immediate onsite corrective actions by the Director of Nursing.
4. Audit findings will be presented to the QA Committee monthly x 3, then quarterly thereafter for evaluation and follow up.

FF10 483.45(d)(e)(1)-(2):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: 483.45(d) Unnecessary Drugs-General. Each resident?s drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used-- (1) In excessive dose (including duplicate drug therapy); or (2) For excessive duration; or (3) Without adequate monitoring; or (4) Without adequate indications for its use; or (5) In the presence of adverse consequences which indicate the dose should be reduced or discontinued; or (6) Any combinations of the reasons stated in paragraphs (d)(1) through (5) of this section. 483.45(e) Psychotropic Drugs. Based on a comprehensive assessment of a resident, the facility must ensure that-- (1) Residents who have not used psychotropic drugs are not given these drugs unless the medication is necessary to treat a specific condition as diagnosed and documented in the clinical record; (2) Residents who use psychotropic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews conducted during a recertification survey, the facility did not ensure behavior monitoring were conducted for residents receiving antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications (Residents #91 and #231). Specifically, there were no behavior monitoring necessary to recognize, evaluate and modify the medication regimen when appropriate. The findings are: 1. Resident # 91 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident assessment tool) of 8/25/16 indicated the resident was receiving antipsychotic medications during the last seven days of this assessment period. The (MONTH) (YEAR) care plan for [MEDICAL CONDITION] Drug Use had interventions including to assess ongoing need for psychotherapeutic medication by monitoring mood and behavior daily, monitor effectiveness of medication, evaluate for side effects, taper (medication) to lowest therapeutic dose per physician recommendations, and report changes in behavior to the physician. The 10/25/16 psychiatric consultation report indicated that the resident had been receiving [MEDICATION NAME] 1 mg in the morning and 1.25 mg at bedtime. The psychiatric consultation report of 12/7/16, signed by the primary physician, indicated that a Gradual Dose Reduction (GDR) was in progress. The recommendation was to decrease [MEDICATION NAME] from 1 mg at bedtime to 0.5 mg at bedtime. The consultation report indicated that the benefits of the GDR include decreased risk of cardiovascular disease. The physician was interviewed on 1/10/17 at 11:05 AM and stated he was in agreement with the recommendation for GDR of the medication. The resident's clinical record revealed no documented evidence that daily mood and behavior monitoring were conducted. There had been monitoring done for the month of (MONTH) (YEAR) but none after this period. The unit Licensed Practical Nurse (LPN #6) was interviewed on 1/10/17 at 11:00 AM regarding behavior monitoring for the resident and stated that the monitoring should be done for this resident. LPN #6 reviewed a binder where the monitoring should be be recorded and could not find any monitoring for this resident since the GDR for the medication in December. The Director of Nursing was interviewed on 1/11/16 at 12:30 PM and stated that all residents receiving antipsychotic medications require documentation of behavior monitoring. The facility policy on Behavior Monitoring Policy updated on 12/4/14 indicated to to monitor and record resident behavior, nursing intervention and outcome utilizing the behavior/intervention monitoring flow record. This monitoring form is also to be used for drug classes including antianxiety, antidepressant, antipsychotic, and sedative/hypnotic medications. 2. Resident #231 has [DIAGNOSES REDACTED]. The Admission MDS of 12/20/17 indicated that the resident was receiving insulin, antipsychotic, antidepressant and diuretic medications during the last seven days of this assessment period. The 12/13/16 care plan for [MEDICAL CONDITION] Drug Use had interventions including to obtain psychiatric consultation and establish appropriate diagnosis, assess ongoing need for psychotherapeutic medication by monitoring mood and behavior daily, evaluate action of medication and side effects, taper medications to lowest therapeutic dose per physician's recommendations and report changes in behavior to the physician. The psychiatric consultation report dated 12/20/16 indicated that the resident informed the psychiatrist that he has [MEDICAL CONDITION] disorder and has been taking his medications. The report further stated that the resident felt the medications [MEDICATION NAME] 50 mg twice a day (an antidepressant) and [MEDICATION NAME] 37.5 mg (an antidepressant) twice a day are working and did not want to change them. The resident's clinical record was reviewed and revealed no documented evidence that behavior monitoring was being done for this resident. The LPN charge nurse (LPN #7) was interviewed on 1/10/17 at 12:30 PM and stated that the resident doesn't have any behaviors to document and that being on an antipsychotic medication doesn't automatically mean that behavior monitoring needs to be done. LPN #7 further stated that behavior monitoring is done if there is a consistent behavior that is being exhibited and they want to capture it, and make recommendations to the psychiatrist. The Director of Nursing was interviewed on 1/11/16 at 12:30 PM regarding behavior monitoring and stated that all residents receiving antipsychotic medications require behavior monitoring. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJanuary 26, 2017

F329

I. Immediate Corrections
Resident#91:
1. The DNS and attending physician reassessed the resident and reviewed the plan of care. It was determined that the current plan of care is appropriate to this resident?s needs.
2. The DNS provided educational counseling to LPN #6 for failing to ensure that the plan of care was followed and the resident?s mood and behavior was monitored and documented. A copy of the counseling was filed for reference and validation.
3. Currently, the resident resides in the facility with all needs met.
Resident#231:
1. The DNS and attending physician reassessed the resident and reviewed the plan of care. It was determined that the current plan of care is appropriate to this resident?s needs.
2. The DNS provided educational counseling to LPN #7 for failing to ensure that the plan of care was followed and the resident?s mood and behavior was monitored and documented. A copy of the counseling was filed for reference and validation.
3. Currently, the resident resides in the facility with all needs met.
II. Identification of Other Residents
1. The DNS identified all residents currently receiving antipsychotic medications. This list was used to validate that these residents were being monitored for mood and behavior per facility policy.
2. The DNS maintained a list of any corrections.
III. Systemic Changes
1. The DNS reviewed the policy on antipsychotic medications and monitoring of mood and behavior and found same to be compliant.
2. All licensed and certified nursing staff and social workers will be provided inservice education on antipsychotic medications and monitoring of mood and behavior by the DNS. The lesson plan will concentrate on the following:
a. Review of facility policy and procedure on mood and behavior monitoring for residents receiving antipsychotic medication;
b. Procedures for documenting mood and behavior observations; and
c. Notifying the physician concerning changes in mood and behavior.
3. The lesson plan and attendance will be filed for reference and validation.
IV. QA Monitoring
1. The DNS developed an audit tool to validate compliance with facility policy on mood and behavior observation and documentation for residents receiving antipsychotic medication.
2. Audits will be done by the DNS/designee on all residents receiving antipsychotic medication initially, then 10% of all residents receiving antipsychotic medications monthly.
3. Audits with negative findings will have immediate corrective action and will be referred to the DNS/Medical Director for follow-up.
4. Findings of audits will be presented to the Q.A. Committee on a quarterly basis for evaluation and follow up

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

Based on observations and interviews conducted during a recertification survey, the facility did not ensure that meals are handled and served to residents under sanitary conditions in 4 of 4 facility dining rooms. The findings are: 1. A lunch meal dining observation in the large main dining room in the basement of the facility was conducted on 1/4/17 at noon. This dining room was occupied by 100 residents. Multiple improper handling of food items were observed in the sensory program section of this dining room where many staff members were needed to assist the residents. A Recreational Assistant (RA) #1 was observed assisting one resident opening a bread package, and breaking up and handing the bread to the resident with bare hands. RA #1 was interviewed on 1/4/17 at 12:45 PM and stated that she didn't realize that she was doing something incorrectly. During the same lunch meal, a different RA #2 was assisting a resident #104 with opening his straw. RA #2 touched the entire straw without any barrier, and used it to stir the residents' coffee. RA #2 was interviewed and stated he didn't realize he was touching the end of the straw that the resident was going to use. A second lunch meal observation was conducted on 1/6/17 at noon on the sensory section of the large main dining room. A Rehab Assistant (PTA #1) was observed buttering the resident's bread while placing it directly on his bare hand. PTA #1 was interviewed and stated that he needs to make sure his hands are washed before he assists the residents.
2. During initial tour of the facility kitchen on 1/4/17 at 9:30 AM, the food that had been cooked and cooled (macaroni, cheese, and pureed starch) were observed in the refrigerator. The Food Service Director (FSD) was interviewed on 1/10/17 at 1:15 PM regarding the foods that were cooked and cooled. The FSD stated they cook and cool certain foods, for example, roast beef was to be reheated and served the next day and chicken for chicken salad. When asked how the roast beef is cooled, the FSD stated he lets it sit out for a short time then cuts it into smaller pieces and puts it back in the refrigerator. When asked about cooling logs to make sure food is cooled to the proper temperature in the established time frame, the FSD stated he does not have them. Potentially hazardous foods requiring refrigeration must be cooled by an adequate method so that every part of the product is reduced from 120 degrees Fahrenheit (F) to 70 degrees F within 2 hours, and from 70 degrees F to 45 degrees F or below within 4 additional hours. Bacteria that cause food poisoning grow at temperatures between 45 degrees and 120 degrees F. The cooling requirement limits the length of time that potentially hazardous food is in the temperature range at which harmful bacteria can grow. (http://www.health.ny.gov/environmental/indoors/food_safety/coolheat.htm) 415.14(h)

Plan of Correction: ApprovedJanuary 26, 2017

F371
I. Immediate Corrections
1. The DNS provided educational counseling to RA #1, RA #2, and PTA #1 for failing to ensure that the residents received meals in full recognition of their dignity, and in compliance with infection control and sanitation. A copy of the counseling was filed for reference and validation.
2. The Administrator, Director of Nursing, and the Registered Dietician reviewed the facility policy and procedure on Resident Dining, dignity, infection control, and sanitation and the proper method of disposing of refuse and found same to be compliant.
3. All licensed and certified nursing staff, dietary aides, recreation staff, and ancillary staff assisting with the meal pass will be inserviced by the Director of Nursing on dignity relative to the residents? dining experience, infection control, and sanitation. The lesson plan will concentrate on the following:
a. Review of the intent and interpretive guidelines for F241 Dignity;
b. Review of the intent and interpretive guidelines for F371 Food Service and Sanitation;
c. Review of the facility policy and procedure on Resident Dining dignity, infection control, and sanitation and the proper method of disposing of refuse
d. The lesson plan and attendance will be filed for validation.
4. All residents currently receive meals in full recognition of their dignity and in compliance with facility policy on infection control, and sanitation and the proper method of disposing of refuse during the meal pass.
5. The Administrator provided educational counseling to the Food Service Director for failure to ensure that foods were properly cooled before being stored in the refrigerator. A copy of the counseling was filed for validation.
6. The Administrator and FSD reviewed and revised the facility policy and procedure on cooling foods requiring refrigeration to include the use of a cooling log.
7. The Food Service Director immediately inserviced the food service staff on the revised policy and the proper procedure for cooling foods that require refrigeration.
8. The attendance and lesson plan was filed for validation.
II. Identification of Other Residents
1. The facility respectfully submits that all residents were potentially affected by the deficient practice.
III. Systemic Changes
1. The Administrator, Director of Nursing, and the Registered Dietician reviewed the facility policy and procedure on Resident Dining, dignity, infection control, and sanitation and the proper method of disposing of refuse and found same to be compliant.
2. All licensed and certified nursing staff, dietary aides, recreation staff, and ancillary staff assisting with the meal pass will be inserviced by the Director of Nursing on dignity relative to the residents? dining experience, infection control, and sanitation. The lesson plan will concentrate on the following:
a. Review of the intent and interpretive guidelines for F241 Dignity;
b. Review of the intent and interpretive guidelines for F371 Food Service and Sanitation;
c. Review of the facility policy and procedure on Resident Dining dignity, infection control, and sanitation and the proper method of disposing of refuse
d. The lesson plan and attendance will be filed for validation.
3. The Administrator and FSD reviewed and revised the facility policy and procedure on cooling foods requiring refrigeration to include the use of a cooling log.
4. The Food Service Director inserviced the food service staff on the revised policy and the proper procedure for cooling foods that require refrigeration.
5. The attendance and lesson plan was filed for validation.
IV. QA Monitoring
1. The Director of Nursing and Registered Dietician developed an audit tool to monitor the dignity, infection control, and sanitation during Resident dining.
2. Audits will be done by the DNS/designee on all units weekly for the first quarter, and then quarterly and at random thereafter.
3. Audits with negative findings will have immediate onsite corrective actions by the Director of Nursing.
4. Audit findings will be presented to the QA Committee monthly x 3, then quarterly thereafter for evaluation and follow up.
5. The Food Service Director developed an audit tool to track the proper cooling of foods requiring refrigeration.
6. Audits will be done by Food Service staff daily for the first month and weekly thereafter.
7. Audits with negative findings will have corrective actions implemented by the FSD.
8. Audit findings will be presented to the QA Committee quarterly for evaluation and follow up

FF10 483.45(f)(1):FREE OF MEDICATION ERROR RATES OF 5% OR MORE

REGULATION: (f) Medication Errors. The facility must ensure that its- (1) Medication error rates are not 5 percent or greater;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review, the facility did not ensure that its medication error rate was less than 5%. Specifically, 4 medication errors were observed out of 28 opportunities for errors (number of medication doses given) resulting in a medication error rate of 14.28%, for 3 out of 5 residents (#232, #37 and #163) observed during a medication pass. The findings are: 1. Resident #163 has [DIAGNOSES REDACTED]. During a medication pass on 1/6/17 at 9:15 AM, the unit medication Licensed Practical Nurse #1 was observed to administer [MEDICATION NAME] 500 mg 1 tablet by mouth to Resident #163. LPN #1 then handed to the surveyor the blister pack containing the daily doses of the medication. Upon review of the blister pack, an instruction was inscribed on the label of the medication to give the medication with meals. LPN #1 was interviewed at that time and stated that she usually administers the medication to this resident at around the time of the surveyor's observation. LPN #1 stated that the resident had her breakfast at around 8:00 AM and stated further that she should have administered the medication during or immediately after breakfast an hour ago. LPN #1 stated that she did not notice the instruction written on the label to give the medication with meals. The resident's current physician's orders [REDACTED]. 2. Resident #37 has [DIAGNOSES REDACTED]. During a medication pass on 1/6/17 at 10:00 AM, the Licensed Practical Nurse (LPN #2) administered the resident's medications including, but are not limited to, Chewable Aspirin 81 mg 1 tablet by mouth to Resident #37. The medications administered by LPN #2 was reviewed against the current physician's orders [REDACTED]. LPN #2 was interviewed after review of the medication orders and stated she only have one form of aspirin which was the chewable form, which was ordered by the physician. LPN #2 reviewed the physician's orders [REDACTED]. The resident's attending physician was interviewed on 1/6/17 at approximately 10:15 AM and stated he ordered the [MEDICATION NAME] form of the aspirin to prevent stomach discomfort. 3. Resident #232 has [DIAGNOSES REDACTED]. The unit medication LPN #3 was observed to administer [MEDICATION NAME] 6.25 mg 1 tablet and [MEDICATION NAME] 500 mg 1 tablet by mouth to the resident. LPN #3 handed the blister packs of the medications to the surveyor and upon reading the instructions inscribed on the labels of the medications, it revealed that both medications should be given with food or milk. The medications administered was reviewed against the physician's orders [REDACTED]. LPN #3 was interviewed on 1/6/17 at 10:30 AM and stated that the medications should have been given with food or milk per instructions to avoid possible abdominal discomfort. 415.12(m)(1)

Plan of Correction: ApprovedJanuary 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F332
I. Immediate Corrective Action:
Resident # 163
1. The DNS reviewed the current physician?s order for [MEDICATION NAME] and found same to be correct.
2. The DNS provided an educational counseling to LPN #1 for failing to ensure the medication was given at 8:00 AM with meals, as ordered.
3. A copy of the educational counseling is filed for reference and validation.
4. The resident continues to receive [MEDICATION NAME] as per physician order.
Resident # 37
1. The DNS reviewed the current physician?s order for Aspirin EC Low Dose Oral Tablet Delayed Release 81 mg and found same to be correct.
2. The DNS provided an educational counseling to LPN #2 for failing to ensure the right form of the medication was given, as ordered.
3. A copy of the educational counseling is filed for reference and validation.
4. The resident continues to receive Aspirin EC Low Dose Oral Tablet Delayed Release 81 mg as per physician order.
Resident #232
1. The DNS reviewed the current physician?s order for [MEDICATION NAME] 6.25 mg and [MEDICATION NAME] 500 mg and found same to be correct.
2. The DNS provided an educational counseling to LPN #3 for failing to ensure the medications were administered with food or milk, as ordered.
3. A copy of the educational counseling is filed for reference and validation.
4. The resident continues to receive [MEDICATION NAME] 6.25 mg and [MEDICATION NAME] 500 mg as per physician order [REDACTED].
II. Identification of Other Residents:
Resident #163
1. The DNS/RN Supervisors identified all residents with physician orders [REDACTED].
2. This list was then used by the DNS/RN Supervisors to review all MARs to ensure that all medication ordered at specific times is followed by the medication nurses.
3. All licensed nurses received a Medication Competency Observation by the RN Supervisor to ensure medications are administered at the physician ordered times.
4. No further quality issues were identified.
Resident #37
1. The DNS/RN Supervisors identified all residents with physician orders [REDACTED].
2. This list was then used by the DNS/RN Supervisors to review all MARs to ensure that all medication is administered in the correct form.
3. All licensed nurses received a Medication Competency Observation by the RN Supervisor to ensure medications are administered in the correct form.
4. No further quality issues were identified.
Resident #232
1. The DNS/RN Supervisors identified all residents with physician orders [REDACTED].
2. This list was then used by the DNS/RN Supervisors to review all MARs to ensure that all medication ordered to be administered with food or milk is followed by the medication nurses.
3. All licensed nurses received a Medication Competency Observation by the RN Supervisor to ensure medications are administered with food or milk, as ordered.
4. No further quality issues were identified.
III. Systemic Changes
1. The DNS, in conjunction with the pharmacy consultant, reviewed the policy and procedure on medication administration and found same to be compliant.
2.Milk and pudding will be available during the medication pass to ensure that the medications that are ordered to be administered with food can be done so if the actual meal has concluded.
3. All licensed nurses will be re-in serviced on medication administration by the DNS. The Lesson Plan will concentrate on:
a. 5 rights of medication administration, including:
i. Time of med to be administered
ii. Dosage of med to be administered
iii. Ensuring all medications were administered as ordered
3. A copy of the Lesson Plan and attendance records will be filed for reference and validation.
4. All licensed nurses will have on-going medication pass observation by the RN Supervisor/Pharmacy Consultant. Nurses identified with negative findings will be re-in serviced and a follow-up med pass observation performed.
IV. QA Monitoring:
1. The DNS, in conjunction with the pharmacy consultant, developed a nurse competency audit tool to ensure compliance with medication administration.
2. Nurse competency observation will performed by the RN Supervisor/Pharmacy Consultant on each nurse monthly for the next three months, then random observations will be conducted quarterly.
3. Audits with negative findings will have immediate corrective action and be referred to the DNS for follow-up.
4. Audit findings will be presented to the QA Committee quarterly by the Administrator for evaluation and follow up.

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interview conducted during a recertification survey, the facility did not ensure that behavior monitoring were conducted based on the written care plans for residents receiving antipsychotic medications for 2 of 5 residents reviewed for unnecessary medications (Residents #91 and #231). The findings are: 1. Resident # 91 has [DIAGNOSES REDACTED]. The Annual Minimum Data Set (MDS; a resident assessment tool) of 8/25/16 indicated the resident was receiving antipsychotic medications during the last seven days of this assessment period. The (MONTH) (YEAR) care plan for [MEDICAL CONDITION] Drug Use had interventions including to assess ongoing need for psychotherapeutic medication by monitoring mood and behavior daily, monitor effectiveness of medication, evaluate for side effects, taper (medication) to lowest therapeutic dose per physician recommendations, and report changes in behavior to the physician. The 10/25/16 psychiatric consultation report indicated that the resident had been receiving [MEDICATION NAME] 1 mg in the morning and 1.25 mg at bedtime. The psychiatric consultation report of 12/7/16, signed by the primary physician, indicated that a Gradual Dose Reduction (GDR) was in progress. The recommendation was to decrease [MEDICATION NAME] from 1 mg at bedtime to 0.5 mg at bedtime. The consultation report indicated that the benefits of the GDR include decreased risk of cardiovascular disease. The physician was interviewed on 1/10/17 at 11:05 AM and stated he was in agreement with the recommendation for GDR of the medication. The resident's clinical record revealed no documented evidence that daily mood and behavior monitoring was conducted. There had been monitoring done for the month of (MONTH) (YEAR) but none after that. The unit Licensed Practical Nurse (LPN #6) was interviewed on 1/10/17 at 11:00 AM regarding behavior monitoring for the resident and stated that the monitoring should be done for this resident. LPN #6 reviewed a binder where the monitoring should be be recorded and could not find any monitoring for this resident since the GDR for the medication in December. The Director of Nursing was interviewed on 1/11/16 at 12:30 PM and stated that all residents receiving antipsychotic medications require documentation of behavior monitoring. The facility policy on Behavior Monitoring Policy updated on 12/4/14 indicated to to monitor and record resident behavior, nursing intervention and outcome utilizing the behavior/intervention monitoring flow record. This monitoring form is also to be used for drug classes including antianxiety, antidepressant, antipsychotic, and sedative/hypnotic medications. 2. Resident #231 has [DIAGNOSES REDACTED]. The Admission MDS of 12/20/17 indicated that the resident was receiving insulin, antipsychotic, antidepressant and diuretic medications during the last seven days of this assessment period. The 12/13/16 care plan for [MEDICAL CONDITION] Drug Use had interventions including to obtain psychiatric consultation and establish appropriate diagnosis, assess ongoing need for psychotherapeutic medication by monitoring mood and behavior daily, evaluate action of medication and side effects, taper medications to lowest therapeutic dose per physician's recommendations and report changes in behavior to the physician. The psychiatric consultation report dated 12/20/16 indicated that the resident informed the psychiatrist that he has [MEDICAL CONDITION] disorder and has been taking his medications. The report further stated that the resident felt the medications [MEDICATION NAME] 50 mg twice a day (an antidepressant) and [MEDICATION NAME] 37.5 mg (an antidepressant) twice a day are working and did not want to change them. The resident's clinical record was reviewed and revealed no documented evidence that behavior monitoring was being done for this resident. The LPN charge nurse (LPN #7) was interviewed on 1/10/17 at 12:30 PM and stated that the resident doesn't have any behaviors to document and that being on an antipsychotic medication doesn't automatically mean that behavior monitoring needs to be done. LPN #7 further stated that behavior monitoring is done if there is a consistent behavior that is being exhibited and they want to capture it, and make recommendations to the psychiatrist. The Director of Nursing was interviewed on 1/11/16 at 12:30 PM regarding behavior monitoring and stated that all residents receiving antipsychotic medications require behavior monitoring. 415.11(c)(3)(ii)

Plan of Correction: ApprovedJanuary 26, 2017

F282
I. Immediate Corrections
Resident#91:
1. The DNS and attending physician reassessed the resident and reviewed the plan of care. It was determined that the current plan of care is appropriate to this resident?s needs.
2. The DNS provided educational counseling to LPN #6 for failing to ensure that the plan of care was followed and the resident?s mood and behavior was monitored and documented. A copy of the counseling was filed for reference and validation.
3. Currently, the resident resides in the facility with all needs met.
Resident#231:
1. The DNS and attending physician reassessed the resident and reviewed the plan of care. It was determined that the current plan of care is appropriate to this resident?s needs.
2. The DNS provided educational counseling to LPN #7 for failing to ensure that the plan of care was followed and the resident?s mood and behavior was monitored and documented. A copy of the counseling was filed for reference and validation.
3. Currently, the resident resides in the facility with all needs met.

II. Identification of Other Residents
1. The DNS identified all residents currently receiving antipsychotic medications. This list was used to validate that these residents were being monitored for mood and behavior per facility policy.
2. The DNS maintained a list of any corrections.
III. Systemic Changes
1. The DNS reviewed the policy on antipsychotic medications and monitoring of mood and behavior and found same to be compliant.
2. All licensed and certified nursing staff and social workers will be provided inservice education on antipsychotic medications and monitoring of mood and behavior by the DNS. The lesson plan will concentrate on the following:
a. Review of facility policy and procedure on mood and behavior monitoring for residents receiving antipsychotic medication;
b. Procedures for documenting mood and behavior observations; and
c. Notifying the physician concerning changes in mood and behavior.
3. The lesson plan and attendance will be filed for reference and validation.

IV. QA Monitoring
1. The DNS developed an audit tool to validate compliance with facility policy on mood and behavior observation and documentation for residents receiving antipsychotic medication.
2. Audits will be done by the DNS/designee on all residents receiving antipsychotic medication initially, then 10% of all residents receiving antipsychotic medications monthly.
3. Audits with negative findings will have immediate corrective action and will be referred to the DNS/Medical Director for follow-up.
4. Findings of audits will be presented to the Q.A. Committee on a quarterly basis for evaluation and follow up

Standard Life Safety Code Citations

K307 NFPA 101:DISCHARGE FROM EXITS

REGULATION: Discharge from Exits Exit discharge is arranged in accordance with 7.7, provides a level walking surface meeting the provisions of 7.1.7 with respect to changes in elevation and shall be maintained free of obstructions. Additionally, the exit discharge shall be a hard packed all-weather travel surface. 18.2.7, 19.2.7

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

2012 NFPA 101 - Chapter 7 Means of Egress 7.1.6 Walking Surfaces in the Means of Egress. 7.1.6.4* Slip Resistance. Walking surfaces shall be slip resistant under foreseeable conditions. The walking surface of each element in the means of egress shall be uniformly slip resistant along the natural path of travel. Based on observation and interview, the facility did not ensure that the discharge exits in the dining room on the first floor were slip resistant. This was evidenced by the walking surfaces of the means of egress on the exterior side of the two sets of emergency exit doors from the dining room that were not free of ice and snow. The findings are: On 1/9/17 at approximately 1:40 PM, a tour of the main dining room located on the first floor was conducted. It was noted that the walking surfaces of the means of egress from two sets of emergency exit doors had snow and ice directly in front of the doors. In an interview at the time of the finding, the Director of Operations could not provide an explanation as to why the snow and ice was not removed directly in front of the emergency exits doors. 2012 NFPA 101: 7.1.6, 7.1.6.4* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

K 271 P(NAME)
IMMIDEATE CORRECTIVE ACTION
(*correction: the first floor main dining room = lobby floor recreation room)
Upon identification of the snow and ice directly in front of the two emergency exit doors in the lobby recreation room, the snow and ice was removed and the area was salted.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS WHICH MAY BE AFFECTED.
The D.O.O. surveyed all of the facility?s emergency exit doors that may be affected by the same findings. It was found that all other emergency door pathways were compliant with the standard.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE
The D.O.O. and administrator reviewed and revised the facility Policy for ?SNOW/SNOW STORM/ BLIZZARD/ ICE CONDITIONS.? The revision made. The D.O.O./Designee will monitor all the facility emergency exit pathways during a snow or ice condition to assure compliance with the standard. The Housekeeping & Maintenance staff was in-serviced on the revised policy.
4. QA MONITORING
The D.O.O. will perform audits during snow or ice conditions to assure compliance and report to QAPI committee quarterly.

K307 NFPA 101:EGRESS DOORS

REGULATION: Egress Doors Doors in a required means of egress shall not be equipped with a latch or a lock that requires the use of a tool or key from the egress side unless using one of the following special locking arrangements: CLINICAL NEEDS OR SECURITY THREAT LOCKING Where special locking arrangements for the clinical security needs of the patient are used, only one locking device shall be permitted on each door and provisions shall be made for the rapid removal of occupants by: remote control of locks; keying of all locks or keys carried by staff at all times; or other such reliable means available to the staff at all times. 18.2.2.2.5.1, 18.2.2.2.6, 19.2.2.2.5.1, 19.2.2.2.6 SPECIAL NEEDS LOCKING ARRANGEMENTS Where special locking arrangements for the safety needs of the patient are used, all of the Clinical or Security Locking requirements are being met. In addition, the locks must be electrical locks that fail safely so as to release upon loss of power to the device; the building is protected by a supervised automatic sprinkler system and the locked space is protected by a complete smoke detection system (or is constantly monitored at an attended location within the locked space); and both the sprinkler and detection systems are arranged to unlock the doors upon activation. 18.2.2.2.5.2, 19.2.2.2.5.2, TIA 12-4 DELAYED-EGRESS LOCKING ARRANGEMENTS Approved, listed delayed-egress locking systems installed in accordance with 7.2.1.6.1 shall be permitted on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system or an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4 ACCESS-CONTROLLED EGRESS LOCKING ARRANGEMENTS Access-Controlled Egress Door assemblies installed in accordance with 7.2.1.6.2 shall be permitted. 18.2.2.2.4, 19.2.2.2.4 ELEVATOR LOBBY EXIT ACCESS LOCKING ARRANGEMENTS Elevator lobby exit access door locking in accordance with 7.2.1.6.3 shall be permitted on door assemblies in buildings protected throughout by an approved, supervised automatic fire detection system and an approved, supervised automatic sprinkler system. 18.2.2.2.4, 19.2.2.2.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

7.2.1.6.1 Delayed- Egress Locking Systems 7.2.1.6.1.1 Approved, listed, delay-egress locking systems shall be permitted to be installed on door assemblies serving low and ordinary hazard contents in buildings protected throughout by an approved, supervised automatic fire detection system in accordance with Section 9.6 or an approved, supervised automatic sprinkler in accordance with Section 9.7, and where permitted in Chapters 11 through 43, provided that all of the following criteria are met: (4)* A readily , durable sing in letter not less than an inch. (25 mm) high and not less than 1/8 in. (32 mm) in stroke width on a contrasting background that reads as follows shall be located on the door leaf adjacent to the release device in the direction of egress: PUSH UNTIL ALARM SOUNDS DOOR CAN BE OPENED IN 15 SECONDS Based on observation and interview, the facility did not ensure that the discharge exits in the main dining room had delayed egress signs posted. This was evidenced by the two sets of emergency exits doors that lacked delayed egress signage. The findings are: On 1/9/17 at approximately 1:40 PM, a tour of the main dining room located on the first floor was conducted. It was noted that the two sets of double doors which are equipped with delayed egress devices and serve as emergency exits lacked delayed egress signage. In an interview at the time of the finding, the Director of Operations could not provide an explanation as to why delayed egress signs were not previously posted. He stated that delayed egress signage will be immediately posted on the doors. 2012 NFPA 101: 7.1.6, 7.1.6.4* 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

K 222 P(NAME)

1. IMMEDIATE CORRECTIVE ACTION:
(*correction: the first floor main dining room = lobby floor recreation room)

Upon identification of the lack of signage for the two emergency exit doors that are equipped with delayed egress devices, located in the lobby floor recreation room, signage was posted on the two doors.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS WHICH MAY BE AFFECTED:
The D.O.O. surveyed all of the facilities emergency exit doors that are equipped with delayed egress devices to assure that other areas are not affected by the same findings. All emergency exit doors that are equipped with delayed egress devices were found to be compliant with the standard.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ENSURE COMPLIANCE:

The D.O.O. and administrator reviewed and revised the facility Policy for emergency exit doors that are equipped with a delayed egress device to assure the facility stays in compliance with the standard.
The Maintenance staff was in-serviced on the revised policy.
The D.O.O. will perform monthly audits for three months and then quarterly on each emergency exit doors equipped with a delayed egress device to assure signage is posted.
4. QA MONITORING
The D.O.O. will perform audits monthly for six months and then quarterly, for the compliance of door signage and report to QAPI committee quarterly.

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: January 10, 2017
Corrected date: February 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Electrical equipment - Power cords and extension cords. 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 NFPA 99 10.2.4. Based on observation and staff interview, it was determined that the facility did not ensure that extension cords and 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 in resident rooms and patient care areas and an extension cord daisy-chained to a relocatable power tap in a vestibule. This was noted on 2 of 4 resident floors and the Rehab room. The findings are: During the Life Safety tour conducted on 1/9/17 and 1/10/16 between the hours of 11:00 AM to 2:00 PM the following issues were noted: - At approximately 11:00 AM, a tour of resident room [ROOM NUMBER] was conducted and it was noted that a relocatable power tap model # E was plugged into an electrical outlet. The resident's clock and radio were plugged into the power tap. - At approximately 12:05 PM, a tour of the first floor was conducted. It was noted that there is a vestibule near a door that exits to the patio. An extension cord was noted above the ceiling tile and daisy-chained to a relocatable power tap in the vestibule. The extension cord was plugged into the electrical outlet above the ceiling tile. The centrifuge and a refrigerator were plugged into the power tap. - At approximately 1:20 PM, a tour of the Rehab was conducted. It was noted that a Belkin brand relocatable power tap model # F 9P609-3 was plugged into the electrical outlet. The computer equipment in the room was plugged into the power tap. In an interview at the time of the findings, the Director of Operations stated that he was unable to locate the manufacturer's specifications for the power taps. He further stated that the refrigerator in the vestibule will be removed. 2012 NFPA 101 2012 NFPA 99: 10.2.3.6, 10.2.4 2011 NFPA 70 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K920 P(NAME)

1. IMMEDIATE CORRECTIVE ACTIONS:
Upon identification, the relocatable power tap model # E was removed from service. A UL model # 1363 power tap was installed in resident room [ROOM NUMBER] to be compliant with the standard.
Upon identification, the extension cord and the relocatable power tap were removed to be compliant with the standard.
Upon identification the Belkin power tap model # F9P609-3 was removed from service to assure compliance with the standard.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS WHICH MAY BE AFFECTED:
The D.O.O. surveyed the facility for other areas that may have extension cords ?daisy chained.? All areas are in compliance with the standard.
The D.O.O. surveyed the facility for other areas that may have relocatable power taps that are not in compliance with the standard. The facility is in compliance with the standard.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ENSURE COMPLIANCE:
The D.O.O. and administrator reviewed and revised the facility Policy for extension cords and Relocatable Power Taps to ensure compliance with the standard.
Rev Made: The D.O.O. will perform monthly audits for three months and then quarterly of all extension cords and relocatable power taps and will inspect them for compliance. The Maintenance staff was in-serviced on the revised policy.
4. QA MONITORING
The D.O.O. will perform monthly audits for three months and then quarterly for the compliance of the relocatable power taps and extension cords and report to the QAPI committee quarterly.

K307 NFPA 101:RUBBISH CHUTES, INCINERATORS, AND LAUNDRY CHU

REGULATION: Rubbish Chutes, Incinerators, and Laundry Chutes 2012 EXISTING (1) Any existing linen and trash chute, including pneumatic rubbish and linen systems, that opens directly onto any corridor shall be sealed by fire resistive construction to prevent further use or shall be provided with a fire door assembly having a fire protection rating of 1-hour. All new chutes shall comply with 9.5. (2) Any rubbish chute or linen chute, including pneumatic rubbish and linen systems, shall be provided with automatic extinguishing protection in accordance with 9.7. (3) Any trash chute shall discharge into a trash collection room used for no other purpose and protected in accordance with 8.4. (Existing laundry chutes permitted to discharge into same room are protected by automatic sprinklers in accordance with 19.3.5.9 or 19.3.5.7.) (4) Existing fuel-fed incinerators shall be sealed by fire resistive construction to prevent further use. 19.5.4, 9.5, 8.4, NFPA 82

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

2012 NFPA 101 - 9.5 Rubbish Chutes, Incinerators, and Laundry Chutes. 9.5.2 Installation and Maintenance. Rubbish chutes, laundry chutes, and incinerators shall be installed and maintained in accordance with NFPA 82, Standard on Incinerators and Waste and Linen Handling Systems and Equipment, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. Based on observation and interview, the facility did not ensure that all doors to the soiled linen chutes located within the soiled linen rooms are maintained self-closing and or latching, in accordance with NFPA 82. This was evidenced by the door to the linen chute on 1 of 4 resident floors that did not latch in the frame when closed. The findings are: On 1/9/17 at approximately 12:35 PM, a tour of the soiled linen chute room located on the first floor was conducted and it was noted that the door to the linen chute did not latch firmly in its frame after self-closing. In an interview at the time of the finding, the Director of Operations stated that the doors to the chutes are checked annually. 2012 NFPA 101: 9.5.2 2009 NFPA 82 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

K 541 P(NAME)

1. IMMEDIATE CORRECTIVE ACTIONS:
Upon identification of the first floor linen chute door that did not latch firmly in its frame after self-closing, the latching device was repaired to be compliant with the standard.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED:
The D.O.O. surveyed the facilities linen chutes on the other floors to assure that other areas are not affected by the same findings. The other linen chute doors are in compliance with the standard.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE:
The D.O.O. and administrator reviewed and revised the Policy for Door Latching.
Rev Made: Re: Audits- the policy Door Latching devices will be tested monthly for six months and then quarterly. The maintenance staff was in-serviced on the revised policy.
4. QA MONITORING
The D.O.O. will perform monthly audits for six months and then quarterly for the compliance of the Door Latching Devices and report to the QAPI committee quarterly.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 10, 2017
Corrected date: February 28, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2011 NFPA 25 Chapter 5 Sprinkler Systems 5.2.1.1.1* Sprinklers shall not show signs of leakage; shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). 2010 NFPA 13 Standard for the Installation of Sprinkler Systems Chapter 8 Installation requirements. 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 the automatic sprinkler system installed in required areas was maintained in accordance with NFPA 25 and NFPA 13 as evidenced by: 1. sprinklers with paint, debris, early signs of corrosion (green discoloration), and/or missing escutcheon plates or bent deflectors; and 2. obstructed sprinkler heads. The findings are: During the Life Safety tour conducted on 1/9/16 and 1/10/17 between the hours of 11:00 AM and 2:00 PM, the following issues with sprinkler heads were noted: - Paint was noted on the sprinklers in resident rooms [ROOM NUMBERS]. - The sprinkler in the walk-in freezer lacked an escutcheon plate and the sprinkler in the corridor adjacent to the walk-in freezer was coated with dirt and debris. - Paint was noted on the sprinkler head located at the bottom landing of stairwell F. - One of two sprinklers in the dish room was green in color and exhibit early signs of corrosion. - The sprinkler in the women's locker room bathroom was obstructed by an electrical cable pole. - One of two sprinklers in the pot wash area was bent. - The sprinkler in the janitor's closet located in the basement was bent. - A tour of the room in the basement containing the hot water tanks and HVAC system revealed inadequate sprinkler coverage in the area of the hot water tanks and the second exit from the room. A sprinkler head in this area could not be located. In an interview at the time of the findings, the Director of Operations stated that the sprinklers are checked annually. He further stated that the paint and debris noted on the sprinklers will be removed and an escutcheon plate installed. The Director of Operations also stated that he will consult with the facility's sprinkler vendor regarding the obstructed sprinkler in the woman's locker room, the bent sprinklers and the missing head in the hot water HVAC system room. 2012 NFPA 101 2011 NFPA 25: 5.2.1.1.1 2010 NFPA 13: 8.8.5.1.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** K 353 P(NAME)
IMMEDIATE CORRECTIVE ACTION
1. Upon identification, the following corrections were made on 01/10/2017
a. The sprinklers in resident room [ROOM NUMBER] and 309 and the sprinkler head located at the bottom landing of stairwell F that were noted with paint, the paint was cleaned off from the sprinklers and are in compliance with the standard.
b. The sprinkler in the walk-in freezer that lacked an escutcheon plate, and escutcheon plate was installed to assure compliance with the standard.
c. The sprinkler in the corridor adjacent to the walk-in freezer that was coated with dirt and debris, it was cleaned to assure compliance with the standard.

A contracted Fire Sprinkler Company was contacted and surveyed the following areas on
01/10/2017.
d. The sprinkler in the dish room that was colored green.
e. The sprinkler in the woman?s locker room bathroom destructed by an electrical cable pole.
f. The sprinkler that is bent in the basement janitor closet and the pot wash area.
g. The basement HVAC/Hot water tank room that had inadequate coverage in the area of the hot water tanks and by the second exit of the room
The fire sprinkler company submitted a proposal for repairs of the non-compliant areas on 01/11/2017. The proposal was signed off on 01/12/2017 and the fire sprinkler company is awaiting for the approval of New York City permits to perform the necessary work.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS WHICH MAY BE AFEECTED:
The D.O.O. surveyed the facility sprinkler heads to assure that other areas are not affected by the same finding. All sprinkler heads were cleaned and all areas requiring sprinkler head coverage was surveyed to assure the facility is in compliance with the standard, and was found to be compliant.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ENSURE COMPLIANCE
The facility contracted with the fire sprinkler company and is awaiting Work Permits to perform the necessary work to correct the findings.
The D.O.O. and administrator reviewed and revised the facility policy for Sprinkler System to assure the facility stays in compliance with the standard.
The D.O.O./designee will perform monthly audits of the sprinkler heads for three months and then quarterly.
The facility maintenance staff was in-serviced on the revised policy to ensure compliance.
4. QA MONITORING
The D.O.O. will perform monthly audits for six months and then quarterly for the compliance of sprinkler heads and report to the QAPI committee quarterly.

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: January 10, 2017
Corrected date: February 28, 2017

Citation Details

2012 NFPA 101 19.3.7 Subdivision of building spaces 19.3.7.3 Any required smoke barrier shall be constructed in accordance with Section 8.5 and shall have a minimum 1/2-hour fire resistance rating, unless otherwise permitted by one of the following: (1) This requirement shall not apply where an atrium is used, and both of the following criteria also shall apply: (a) Smoke barriers shall be permitted to terminate at an atrium wall constructed in accordance with 8.6.7(1)(c). (b) Not less than two separate smoke compartments shall be provided on each floor. Based on observation and interview, it was determined that the smoke barrier walls were not constructed to provide at least a one half hour fire resistance rating in accordance with 2012 NFPA 101. This was evidenced by penetrations and unknown fire rated material that was noted around sprinkler pipes and data cables in the barrier walls. This was observed in 2 of 4 smoke barrier walls. The findings are: On 1/9/17 during the life safety recertification survey that was conducted between 11:00 AM to 2:00 PM, the following issues with barrier walls were noted: - At approximately 11:35 AM, the smoke barrier wall above the ceiling tiles on the 3rd floor was examined. It was noted that there was an approximately 1.5 inch penetration around the BX cables and TV cables. In addition, plaster was noted around the sprinkler pipes and cable wires. In an interview at the time of the findings, the Director of Operations sated that the smoke barrier walls are checked annually and ongoing. - At approximately 11:45 AM, the smoke barrier wall on the 2nd floor was examined. It was revealed that there was an opening approximately 1.5 inch around the BX cable that did not penetrate to the other side of the smoke barrier wall, as well as plaster with an unknown fire rating around the sprinkler pipes and data cables. In an interview at the time of the observation, the maintenance staff member stated that sheet rock and joint compound was installed to prevent the spread of smoke through the smoke barrier walls. 2012 NFPA 101 19.3.7.3 10 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedJanuary 26, 2017

K 372 P(NAME)

1. IMMEDIATE CORRECTIVE ACTION TAKEN
Upon identification of the penetration above the ceiling tiles on the 3rd floor and the 2nd floor, the facilities assistant administrator and the D.O.O. searched in stores and on-line for an approved Tile Barrier Sealant to block the penetrations to assure compliance with the standard. On 01/24/2017 the maintenance department began the project of sealing penetrations with an approved Fire Barrier Sealant.
2. THE FOLLOWING CORRECTIVE ACTIONS WERE IMPLIMENTED TO IDENTIFY OTHER AREAS THAT MAY BE AFFECTED:
The D.O.O. surveyed the facility?s other smoke barrier walls above the ceiling tiles to assure that other areas were not affected by the same findings. Any areas affected by the same findings are in progress of meeting the standard.
3. THE FOLLOWING MEASURES WERE PUT INTO PLACE TO ASSURE COMPLIANCE:
The D.O.O. and administrator reviewed and revised the facility Policy for Penetrations.
Rev Made: Re: Approved Fire Barrier Sealant with a fire rating of no less than 2 hours & the D.O.O. will audit
The hallway fire barriers for penetrations monthly for three months and then quarterly. The Maintenance
Staff was in-serviced on the revised policy.

4. QA MONITORING
The D.O.O. will perform audits of fire barrier walls monthly for three months and then quarterly, for the compliance of fire barriers and report to the QAPI committee quarterly.