Grandell Rehabilitation and Nursing Center
March 15, 2018 Certification Survey

Standard Health Citations

FF11 483.20(g):ACCURACY OF ASSESSMENTS

REGULATION: §483.20(g) Accuracy of Assessments. The assessment must accurately reflect the resident's status.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: April 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the recertification survey the facility did not ensure that each resident receive an accurate assessment reflective of the resident's current status. This was evident for one (Resident #129) resident reviewed for Minimum Data Set (MDS) Accuracy. Specifically, the Quarterly MDS Assessments dated 2/1/18 and 11/2/17 documented the resident's short term memory was ok, however, the Comprehensive Care Plan (CCP) for Cognition documented the resident had short term memory loss. The finding is: Resident #129 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. A Quarterly MDS assessment dated [DATE] documented the resident's short term memory was ok and the resident had no mood or behavior problem. The Quarterly MDS assessment dated [DATE] also documented the resident's short term memory was ok. Resident #129 was observed on 3/6/18 at 9:30 AM awake in bed. The resident responded to her name, however, could not recall what she had for breakfast of if she had breakfast. A CCP dated 2/29/16 for Cognition/Dementia and [MEDICAL CONDITION] documented the resident had impaired cognition with short term and long term memory loss, and had impaired decision making skills. The CCP was updated on 11/6/17 and 2/5/18 and documented the resident's cognition remained unchanged. Interventions included ongoing monitoring of the resident's cognitive function and changes from baseline, and to provide orientation to unit routines. There was no documented evidence in the CCP that the resident's memory fluctuated. A Psychiatric Evaluation dated 2/1/18 documented the resident has short and long term memory loss, was oriented to name only, and had poor insight. A Quarterly Social Service note dated 2/5/18 documented the resident remained cognitively impaired secondary to [DIAGNOSES REDACTED]. An interview was conducted on 3/15/18 at 11:45 AM with the Social Worker (SW). The SW who is responsible to complete Section C- Cognitive Patterns on the MDS, stated that she had completed the last two quarterly assessments and that the resident's short term memory fluctuates. The SW stated at times the resident remembers when her family is coming or what food she had that day. 415.11(b)

Plan of Correction: ApprovedApril 4, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I) Immediate Corrective Actions
Resident #129
1. On 3/14/2018 the Comprehensive Care plan on Cognition for resident #129 was clarified to reflect that her short-term and long-term memory problems fluctuated secondary to her [MEDICAL CONDITION] associated with Parkinson Disease.
2. On 3/14/2018 a discussion was held with her representatives to review her fluctuating cognition and memory problems with the focus on interventions to maximize strengths.
II) Identification of other Residents
1. On 3/30/18 a review of Coding for Section C0700-C was initiated for all annual MDS submissions for the past 90 days.
2. Coding on MDS will be compared to the CCP on cognition to ensure accuracy.
3. Follow up actions will be taken as needed.

III) Systemic changes
1. On (MONTH) 16th (YEAR), the Policy and Procedure for MDS assessments was reviewed and found to be in compliance.
2. On (MONTH) 16th (YEAR) the Resident Assessment Critical Element Pathway was reviewed and facility found to be in compliance.
3. On (MONTH) 3rd Members of the IDT received education specific to section C0700-C of the MDS. Highlights of the lesson plan included:
? The importance of documenting specific statements obtained during staff interview for cognition.
? The importance of clarifying fluctuations in cognition in the evaluation of the comprehensive care plan.
? The importance of listing both strengths and problems in the
Comprehensive Care Plan for Cognition.
IV) Quality Assurance Monitoring
1. A Performance Improvement Project has been developed to ensure accurate documentation and Care Planning with regards to Mental Status Assessment for Section C0700-C1000 in the MDS.
2. An audit tool has been developed to review documentation and care planning with respect to C0700-C1000
3. Audits will be done on all Annual Assessments x 12 months
4. Immediate Corrective Action will be taken when there is a discrepancy with MDS assessment and Care Plan Documentation.
5. Findings of the Audit will be brought to the morning QA meeting for immediate follow up as indicated
6. Findings of the Audits will be reviewed at the quarterly Quality Assurance Meeting.
V) Responsible Parties
1. The Director of Nursing, Assistant Directors of Nursing, Recreation Staff, MDS Nurses, and Social Workers will responsible for education, completion of audits, and monitoring the Performance Improvement Project.

FF11 483.21(b)(1):DEVELOP/IMPLEMENT COMPREHENSIVE CARE PLAN

REGULATION: §483.21(b) Comprehensive Care Plans §483.21(b)(1) The facility must develop and implement a comprehensive person-centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment. The comprehensive care plan must describe the following - (i) The services that are to be furnished to attain or maintain the resident's highest practicable physical, mental, and psychosocial well-being as required under §483.24, §483.25 or §483.40; and (ii) Any services that would otherwise be required under §483.24, §483.25 or §483.40 but are not provided due to the resident's exercise of rights under §483.10, including the right to refuse treatment under §483.10(c)(6). (iii) Any specialized services or specialized rehabilitative services the nursing facility will provide as a result of PASARR recommendations. If a facility disagrees with the findings of the PASARR, it must indicate its rationale in the resident's medical record. (iv)In consultation with the resident and the resident's representative(s)- (A) The resident's goals for admission and desired outcomes. (B) The resident's preference and potential for future discharge. Facilities must document whether the resident's desire to return to the community was assessed and any referrals to local contact agencies and/or other appropriate entities, for this purpose. (C) Discharge plans in the comprehensive care plan, as appropriate, in accordance with the requirements set forth in paragraph (c) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: April 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interview during the recertification the facility did not ensure that each resident had a person centered CCP developed and implemented to meet each resident's medical needs. This was evident for one (Resident #82) resident reviewed for infection. Specifically, Resident #82 was placed on contact precautions due to multiple episodes of loose stool and there was no documented evidence that a CCP with measurable goals and interventions was developed. The finding is: Resident #82 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. A Quarterly Minimum Data Set (MDS) assessment dated [DATE] documented the resident's Brief Interview for Mental Status (BIMS) Score as 15, indicating the resident's cognition was intact. The resident required total assist of one staff member for toileting and was always incontinent of bowel and bladder. During an observation on 03/09/18 at 10:07 AM a set-up for Person Protective Equipment (PPE) was observed out side the resident's door with a sign to see nurse before entering the resident's room. A CCP dated 8/12/16 and last updated 1/23/18 [MEDICAL CONDITION] the resident was at risk for abdominal pain, vomiting and nausea secondary to [DIAGNOSES REDACTED]. Review of the resident's medical record lacked documented evidence of a CCP developed to include the resident was started on Contact Precautions due to episodes of loose stool. A Nurse's Note dated 3/6/18 at 1:28 PM documented the resident was noted with foul smelling loose stool and that the resident reported a feeling of nausea and decreased appetite. The resident was seen by the MD who ordered blood work and a stool specimen. A Nurse's Note dated 3/7/18 at 1:42 PM documented the resident was noted with diarrhea three times this shift, stool collection in process, and the resident was placed on Contact Precautions. A Nurse's Note dated 3/8/18 at 4:24 PM documented the resident had loose stool three times on the shift, lab results pending and that the resident remains on Contact Precautions. At 10:48 PM the resident had two more episodes of loose stool, no discomfort reported and ongoing monitoring continued. A Nurse's Note dated 3/9/18 at 3:07 AM documented Contact Precautions maintained. The Nurse's Note at 10:29 PM documented the resident had two episodes of loose stool on the shift and monitoring continued. An interview was conducted on 3/15/18 at 10:08 AM with the Licensed Practical Nurse (LPN) in charge. The LPN stated when there is a change in a resident's condition she was responsible for initiating a CCP. The LPN stated I suppose a CCP should have been initiated however the resident was placed on precautions because she was having loose stool and they were waiting for Lab results for [MEDICAL CONDITION]. An interview was conducted on 3/15/18 at 10:55 AM with the Registered Nurse (RN) Supervisor who stated the Nursing Care Coordinators (NCC) initiate CCPs. The RN stated that she could not say if a CCP should have been developed for a resident that had loose stool and was placed on Contact Precaution. An interview was conducted on 3/15/18 at 11:30 AM with the Director of Nursing (DNS). The DNS stated that everything was in place but the NCC forgot to initiate the CCP. 415.11(c)(1)

Plan of Correction: ApprovedApril 12, 2018

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I) Immediate Corrective Actions
Resident #82
1. The resident?s stool results were received on 3/9/18 and indicated that [MEDICAL CONDITION] toxin A and B were negative.
2. The Physician discontinued Contact Precautions on 3/9/18.
3. The Resident continued to be monitored closely for 3 days s/p negative test results.
4. The resident?s pre-existing care plan for GI disturbances was reviewed and an evaluation was updated 3/15/18.
II) Identification of other Residents
Facility respectfully states that no other residents were on transmission-based precautions.
III) Systemic changes
1. On (MONTH) 17th (YEAR) the Policy and Procedure Comprehensive Care Planning was reviewed and found to be in compliance.
2. On (MONTH) 17th the General Critical Element Pathway was reviewed with respect to resident #82 and facility was in compliance
3. On (MONTH) 3rd in-service education was provided for all licensed staff on Comprehensive Care Planning. Highlights of the In-service include:
? The steps to take when diagnostic test results are pending including 24- hour report monitoring and pending episodic events.
? The steps to take when transmission based precautions are intiated [MEDICATION NAME] pending culture results.
IV) Quality Assurance Monitoring
1. A Performance Improvement Project has been developed to assure that each resident has a person-centered care plan developed and implemented to meet physical and psycho social needs.
2. An audit tool has been developed to audit compliance with Care Planning for episodic events.
3. Audits will be done for two selected residents experiencing a change in condition on each unit weekly x 3 months then monthly x 9 months.
4. Immediate Corrective Action will be taken when noncompliance is identified.
5. Findings of the Audits will be reviewed at the quarterly Quality Assurance Meeting
V) Responsible parties will be.
1. The Director of Nursing, Assistant Directors of Nursing, and In-service Director will responsible for education, and completion of audit

FF11 483.10(h)(1)-(3)(i)(ii):PERSONAL PRIVACY/CONFIDENTIALITY OF RECORDS

REGULATION: §483.10(h) Privacy and Confidentiality. The resident has a right to personal privacy and confidentiality of his or her personal and medical records. §483.10(h)(l) Personal privacy includes accommodations, medical treatment, written and telephone communications, personal care, visits, and meetings of family and resident groups, but this does not require the facility to provide a private room for each resident. §483.10(h)(2) The facility must respect the residents right to personal privacy, including the right to privacy in his or her oral (that is, spoken), written, and electronic communications, including the right to send and promptly receive unopened mail and other letters, packages and other materials delivered to the facility for the resident, including those delivered through a means other than a postal service. §483.10(h)(3) The resident has a right to secure and confidential personal and medical records. (i) The resident has the right to refuse the release of personal and medical records except as provided at §483.70(i)(2) or other applicable federal or state laws. (ii) The facility must allow representatives of the Office of the State Long-Term Care Ombudsman to examine a resident's medical, social, and administrative records in accordance with State law.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 15, 2018
Corrected date: April 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interviews during the recertification survey the facility did not ensure that each resident's rights to personal privacy and confidentiality of his or her personal and medical record was maintained. This was evident for one of five residents observed for medication administration. Specifically, the Licensed Practical Nurse (LPN) was observed to leave her medication cart in the hallway near the nursing station with the electronic medical record open and the resident's picture and personal information visible to others. The finding is: Resident #128 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. During a medication administration pass conducted on 3/6/18 at 10: 05 AM with the unit LPN, the LPN was observed to walk down the hall leaving the medication cart with the resident's Electronic Medical Record visible to others in the hallway near nurse's station. The LPN was interviewed immediately on 3/6/18 at 10:05 AM. The LPN stated that she was in a hurry to answer the call bell of a resident. The LPN stated the resident needed to be changed. The LPN further stated that before walking away from her computer she should have exited the screen to protect the resident's health information. The Director of Staff Development was interviewed on 3/14/18 at 2:13 PM. He stated the LPN was previously in-serviced regarding protecting resident's health information and that on 3/7/18 the LPN was re-inserviced on privacy of the resident's health information. 415.3(d)(1)(ii)

Plan of Correction: ApprovedApril 4, 2018

(I) Immediate Corrective Actions
Resident 34
1. On (MONTH) 14th (YEAR), the involved licensed practical nurse received education and counseling for failure to maintain privacy of the resident?s electronic medical record screen.
2. On (MONTH) 14th, the resident and representative were informed of the incident and provided with education regarding follow up corrective measures taken.
3. On (MONTH) 14th, all Licensed Nurses received in-service on each resident?s right to personal privacy and confidentiality specific to their electronic medical record.
II) Identification of other Residents
1. All residents have the potential to be affected by this deficient practice
III) Systemic changes
2. On (MONTH) 17th (YEAR) the Policy and Procedure was reviewed regarding HIPPA Compliance and the Protection of Resident?s Electronic Medical Records and was found to be in compliance.
3. On (MONTH) 29th a Competency was developed for securing the electronic medical record when the nurse administering medications needs to respond to an urgent resident care need.
4. On (MONTH) 29th the Medication Administration Policy and the Competency for Medication Administration were amended to include the specific actions to be taken for securing the electronic medical record when responding to an urgent resident care need.
5. On (MONTH) 3rd in-service education for all licensed staff and Department Heads was initiated on the Policy revisions made to ensure resident privacy with respect to the electronic medical record. Highlights of the In-service include:
? The Need to respond to urgent resident needs during emergencies, coupled with the requirement to ensure privacy of their Electronic Medical record.
? The ?1-2-3 Go? Step Approach for protecting the electronic medical record during the medication pass when called to respond to an urgent resident care need.
? Step 1 Sign for medication that was just administered (if indicated)
? Step 2 Close the computer screen
? Step 3 Lock the cart
? Go: Respond to the resident that needs assistance.
6. The revised Competency for Medication Administration will be done on all Licensed staff with emphasis on the ?1-2-3 Go? step approach.
7. The revised Competency for Medication Administration will be done for all new hires during orientation.
8. The Revised Competency for Medication Administration will be done yearly and as needed for all Licensed Nurses.
IV) Quality Assurance Monitoring
1. A Performance Improvement Project has been developed to assure that the Policy for Protecting the Privacy of the Electronic Record is being adhered to.
2. Surveillance of compliance with Protecting the Privacy of the Electronic Medical Record will be done by all members of the IDT when present in resident care areas.
3. An audit tool has been developed to audit compliance with medication administration specific to Protecting the Privacy of the Electronic Medical Record.
4. Audits will be done randomly on all units during the Medication Pass weekly x 3 months and then monthly x 9 months.
5. Immediate Corrective Action will be taken when noncompliance is identified.
6. Findings of the Audits will be reviewed at the quarterly Quality Assurance Meeting
V) Responsible Parties
1. The Director of Nursing, Assistant Directors of Nursing, In-service Director and Pharmacy Consultant will responsible for education, and completion of audits

FF11 483.21(b)(3)(ii):QUALIFIED PERSONS

REGULATION: §483.21(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: March 15, 2018
Corrected date: April 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and staff interviews during the Recertification Survey the facility did not ensure that each resident received care and services in accordance with the written plan of care for 1 of 2 residents reviewed for Pressure Ulcers. Specifically, Resident #122 had a plan of care intervention to float heels on a pillow while in bed; however, the resident was observed on multiple occasions in bed with bare feet and heels resting directly on the mattress. The finding is: Resident #122 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The 1/31/2018 Quarterly Minimum Data Set (MDS) Assessment documented a Brief Interview for Mental Status score of 13, indicating the resident was cognitively intact. The MDS documented the resident required extensive assist of two persons for bed mobility, had functional limitation in range of motion on one side, and was at risk for pressure ulcers but did not have a pressure ulcer. The Braden Scale (a tool for assessing pressure ulcer risk) assessment dated [DATE] documented a score of 15, indicating the resident had a low risk for pressure ulcer development. A Comprehensive Care Plan (CCP), titled Skin Care Prevention, dated 4/28/2017, and last updated 2/1/2018, had an intervention to float heels on a pillow while in bed. A CCP titled Activities of Daily Living (ADLs), dated 4/28/2017, and last updated 12/20/2017, documented the resident had [MEDICAL CONDITION] affecting the right side and required extensive assist of two persons for bed mobility. An evaluation on 12/20/2017 documented the resident frequently refuses to get out of bed and likes to wait for her family to visit after 3 PM. A CCP titled Foot Care, dated 4/28/2017, and last updated 11/8/2017, documented an intervention to provide pressure relieving devices as indicated. A Certified Nursing Assistant (CNA) Accountability Record (CNAAR) dated 2/28/2018 documented an intervention to float heels on a pillow while in bed. A CNAAR dated 3/8/2018 documented an intervention to float heels on a pillow while in bed. On 3/6/2018 at 10:45 AM Resident #122 was observed in bed with bare feet. The heels were resting on the mattress. Her heels were not being floated on pillows. On 3/8/2018 at 10:47 AM and 11:36 AM Resident #122 was observed in bed with bare feet. The heels were resting on the mattress. Her heels were not being floated on pillows. Resident #122's CNA was interviewed on 3/8/2018 at 11:37 AM. She stated the resident required total care and that the staff had to turn the resident because the resident does not turn herself. The CNA further stated the resident slides down in bed and the staff have to pull her up in bed. The Licensed Practical Nurse (LPN) Charge Nurse was interviewed on 3/8/2018 at 11:46 AM and stated that the floating of heels is a resident preference. On 3/8/2018 at 12:41 PM and 1:40 PM Resident #122 was observed in bed with bare feet. The heels were resting on the mattress. Her heels were not being floated on pillows. The Registered Nurse (RN) Assistant Director of Nursing (ADNS) who oversees the fourth floor was interviewed on 3/9/2018 at 1:21 PM. He stated the resident is supposed to have the heels floated, but she refuses. He stated that the refusal was not documented. The Wound Care RN was interviewed on 3/9/2018 at 2:00 PM. She stated that floating of the resident's heels on a pillow was an appropriate intervention. The Director of Nursing Services (DNS) was interviewed on 3/14/2018 at 2:49 PM. She stated that if care plan and CNA interventions are in place then the nurses and CNAs are expected to implement the interventions. The DNS further stated that if a resident is noncompliant the care plan and CNAAR should be updated. 415.11(c)(3)(ii)

Plan of Correction: ApprovedApril 4, 2018

I) Immediate Corrective Actions
Resident #122
1. On (MONTH) 6th (YEAR), an investigation was initiated to determine resident # 122 preference regarding floating of her heels on a pillow.
2. The facility respectfully states that the resident does not and has not had any skin breakdown on heels.
3. On 3/ 8, Resident 122 was interviewed by the Wound Care Nurse and reported she did not want to float her heels on a pillow during the day time.
4. Interview and statements obtained from care-givers from 3/7-3/8 revealed that in the past 72 hours she had been refusing to float heels on occasion during the day and accepts the intervention most nights.
5. On 3/9/18 the IDT reviewed the risk/benefits of floating heels on a pillow and the decision was made to discontinue this intervention and continue with low air loss pressure relief mattress.
6. On 3/9/18 the IDT reviewed resident goals of care with resident and representative and they were in agreement with care plan revisions made to the skin prevention care plan.
II) Identification of other Residents
1. On (MONTH) 11th a house wide review was done of all residents at risk for developing pressure injury to heels and no issues were identified.
2. On (MONTH) 11th a house wide review was done for all residents with pressure relieving devices for heels and compliance with same and no issues were identified.
III) Systemic changes
1. On (MONTH) 11th (YEAR) the Policy and Procedure for Resident Preference and Self Determination was reviewed and found to be in compliance.
2. On (MONTH) 11th a house wide audit was done to identify all residents with pressure relieving devices for heels.
3. Residents care planned for pressure relief devices for heels i.e heel booties/heel lift boots have been added to the Skin Care Prevention List for each unit.
4. On (MONTH) 12th Nursing Staff received education on Residents who refuse interventions as outlined in the plan of care. Highlights of the Lesson Plan include:
? The Nursing Assistants role in reporting resident refusals for intervention(s) listed on the Resident Care Profile.
? The Nurses role in communicating resident refusals to the IDT.
? The IDT responsibility to investigate the root cause of resident refusals, provide resident/representative education, and revise the plan of care accordingly.
5. The Wound Care Nurse will review and revise the Skin Care Prevention List on a weekly basis.
IV) Quality Assurance Monitoring
1. A Performance Improvement Project has been developed to identify residents that refuse interventions as outlined in the plan of care specific to Skin Care Prevention and to ensure that follow up corrective actions are taken by the IDT.
2. An audit tool has been developed to monitor compliance with interventions as listed on the Skin Care Prevention List.
3. Audits will be done on all residents listed on the Skin Care Prevention List on a weekly basis for 3 months and then monthly x 9 months.
4. Immediate Corrective Action will be taken when the Procedure for Noncompliance is not adhered to and/or interventions are not being carried out as listed on the Skin Care Prevention List.
5. Findings of the Audit will be brought to the morning QA meeting for immediate follow up as indicated
6. Findings of the Audits will be reviewed at the quarterly Quality Assurance Meeting.
V) Responsible Parties
1. The Director of Nursing, Assistant Directors of Nursing, Wound Care Nurse, Director of Rehab, and In-service Director will responsible for education, and completion of audits

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: Pattern
Severity: Potential to cause minimal harm
Citation date: March 27, 2018
Corrected date: May 25, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. Include your request for renewal of this waiver, or plan of correction in the space provided on this form. In several areas, doors that open into the corridor, when fully open, project more than 7 inches into the corridor. 483.70(a), 711.2(a)(1), 2012 NFPA 101: 7.7, 7.1.7, 19.2.7, S&C 05-38

Plan of Correction: ApprovedApril 10, 2018

The facility wishes this waiver to be
continued. The conditions under which this
waiver was granted have not changed.

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: March 27, 2018
Corrected date: May 25, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 9.7.5 Maintenance and Testing. All automatic sprinkler and standpipe systems required by this Code shall be inspected, tested , and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems. 2011 NFPA 25: 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. This requirement is not met as evidenced by: Based on observation, documentation review and staff interview, during the recertification survey, the facility did not provide documentation indicating that the dry sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . This was noted for the dry sprinklers in the main kitchen. The findings are: During the Life Safety Code survey of the main kitchen conducted on 03/27/18 at approximately 12:15pm, it was noted that there were dry type sprinklers installed in the walk-in refrigerators and freezer. There was no documentation provided by the facility to indicate that the dry type sprinklers that have been in service for [AGE] years were replaced or that a representative sample was tested . In an interview at this time, the Director of Maintenance stated that the sprinkler company would be contacted to change out the dry type sprinkler heads. 2012 NFPA 101: 9.7.5 2011 NFPA 25: 5.3.1.1.1.6, 5.4.1.4, 5.4.1.4.1 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 13, 2018

Plan of Correction for affected areas.
I. The facility engaged a licensed Sprinkler Company to replace the identified dry sprinkler pendants in the walk-in refrigerators and freezer.
This work will be completed on 5/11/2018.
Plan of Correction to identify other areas potentially affected.
II. The facilities engineering staff checked the entire facility to for dry sprinkler's. No other dry sprinkler pendants were found.
Plan of Correction for system measures to prevent reoccurrence
III. The Preventive Maintenance & Scheduling program will be followed reflecting the daily, weekly, monthly, quarterly, and annual inspection and testing of the sprinkler system throughout the facility. Dry sprinkler pendant replacement will be added to the Preventive Maintenance & Scheduling program.
Plan of Correction for monitoring corrective actions
IV.The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility: Administrator

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

REGULATION: Stairways and Smokeproof Enclosures Stairways and Smokeproof enclosures used as exits are in accordance with 7.2. 18.2.2.3, 18.2.2.4, 19.2.2.3, 19.2.2.4, 7.2

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 27, 2018
Corrected date: May 25, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. Include your request for renewal of this waiver, or plan of correction in the space provided on this form. Outside exit ramps were not protected to prevent the accumulation of snow and ice. 483.70(a), 711.2(a)(1), 2012 NFPA 101: 7.2., 19.2.2.3, 19.2.2.4

Plan of Correction: ApprovedApril 10, 2018

The facility wishes this waiver to be
continued. The conditions under which this
waiver was granted have not changed.

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: March 27, 2018
Corrected date: May 25, 2018

Citation Details

2012 NFPA 101: 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. (2)*Smoke dampers shall not be required in duct penetrations of smoke barriers in fully ducted heating, ventilating, and air-conditioning systems where an approved, supervised automatic sprinkler system in accordance with 19.3.5.8 has been provided for smoke compartments adjacent to the smoke barrier. 2012 NFPA 101: A.19.3.7.3(2) Where the smoke control system design requires dampers in order that the system functions effectively, it is not the intent of the exception to permit the damper to be omitted. This provision is not intended to prevent the use of plenum returns where ducting is used to return air from a ceiling plenum through smoke barrier walls. Short stubs or jumper ducts are not acceptable. Ducting is required to connect at both sides of the opening and to extend into adjacent spaces away from the wall. The intent is to prohibit open-air transfers at or near the smoke barrier walls. Based on observation and staff interview, the facility did not ensure that a smoke damper was installed in duct penetrations of a smoke barrier wall in all locations where they are required. This was noted for rooms in the 16 and 18 lines on six of seven floors. The findings are: On 3/27/18 between 9:30am- 1:30pm during the recertification survey, jumper ducts were noted penetrating smoke barrier walls between resident room bathrooms in the 16 and 18 lines. This was noted on floors 1- 6. The ducts were not provided with motorized smoke dampers. In an interview on 3/27/18 at approximately 10:41am, the Administrator stated that they will look into changing the smoke barriers. 2012 NFPA 101: 19.3.7.3 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 13, 2018

Plan of Correction for affected areas
I. The facility provided three separate smoke compartments on the resident floors identified during the survey. The 2012 NFPA 101: 19.3.7.3(1)(b) only requires a minimum of ?not less than two separate smoke compartments shall be provided on each floor?. The facility will eliminate the smoke barrier designation of the smoke barrier between resident rooms 16 and 18 on the floors identified during the survey. The new smoke compartment does not exceed 22,500 square feet and the travel distance from any point to reach a door in the required smoke barrier does not exceed 200 feet. Signage will be permanently installed on the doors, ?This is not a smoke barrier?. All staff will be in-serviced on the smoke barriers by the facilities in-service coordinator and the Fire Safety consultant. All fire drills will include in-service on the smoke barriers.
This will be completed on 5/11/2018.
Plan of Correction to identify other areas potentially affected
II. On 4/5/2018 the engineering staff conducted an audit throughout the facility for penetrations in smoke barriers. No other areas were found.
Plan of Correction for system measures to prevent reoccurrence
III. The Preventive Maintenance & Scheduling program will be followed reflecting the semi-annual inspection of Fire and Smoke Barriers throughout the facility.
Plan of Correction for monitoring corrective actions
IV. The Facilities Manager or Designee will review monthly environment of care rounds for any cases of non-compliance. The Facilities Manager or Designee will report the result of these audits to the Safety committee on a monthly basis, as well as correction plan if warranted.
Responsibility:
Administrator

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 27, 2018
Corrected date: May 25, 2018

Citation Details

The following requirements of The Life Safety Code have been previously waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the conditions under which the waivers have been granted have not changed. Please indicate if the facility wishes that waiver(s) to be continued. Include your request for renewal of this waiver, or plan of correction in the space provided on this form. 1. Exit stairways were not enclosed with partitions having a fire resistance rating of at least 2 hours. Non-fire proofed steel structural members were incorporated into stairway enclosures. 2. Elevator shafts were not enclosed with partitions having a fire resistive rating of at least 1 hour. Reference is made to the incorporation of non-fire proofed structural members into the shaft construction. 483.70(a), 711.2(a)(1), 2012 NFPA 101: 8.6., 19.3.1.1 through 19.3.1.6

Plan of Correction: ApprovedApril 10, 2018

The facility wishes this waiver to be
continued. The conditions under which this
waiver was granted have not changed.