Cuba Memorial Hospital Inc SNF
June 9, 2017 Certification/complaint Survey

Standard Health Citations

E3BP 402.6(d):CRIMINAL HISTORY RECORD CHECK PROCESS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: July 7, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 6/9/17, the facility lacked documentation of supervision of an employee who was working in direct resident care without being monitored by the Criminal History Record Check (CHRC) program. This affected one (Employee #1) of four employees reviewed for Criminal History Record Checks. The finding is: 1. Review of the personnel file for Employee #1 (Certified Nurse Aide) revealed Employee #1 was hired on 5/26/17 and the Criminal History Record Check (CHRC) determination letter for this employee was dated 6/6/17. Review of Employee #1's Adjustment to Work Schedules revealed Employee #1 worked on the Skilled Nursing Facility Unit 2 on 5/31/17, 6/1/17, 6/2/17, 6/5/17, and 6/6/17. Interview with the Human Resources Manager (Authorized Person) on 6/6/17 at approximately 3:09 PM revealed she has no knowledge of the supervision for Employee #1 while awaiting CHRC results. Interview with the Licensed Practical Nurse (LPN), Resident Care Coordinator (RCC) on 6/6/17 at approximately 3:37 PM revealed she was aware of the supervision requirement for Employee #1 and Employee #1 has been supervised by herself and a Registered Nurse, when on duty, but she has no documentation to support this. Review of the facility policy entitled Criminal Background Checks, revised 7/15, revealed during the time of legal review the department Manager/ Supervisor of the individual will need to maintain fingerprint signature logs provided by the HR Manager to document close monitoring through this provisional period. 402.4(b)(2)(i)

Plan of Correction: ApprovedJuly 17, 2017

The facility will ensure the supervision requirements are implemented during the period of temporary employment while results of the criminal background check are pending.
All residents have the potential to be affected by this deficient practice. As immediate corrective action a 100% audit of all current employee files were reviewed for CHRC determination letters by the Human Resources supervisor. Any new hire without determination letters will have supervisor tracking forms issued while waiting for CHRC determination letters.
To ensure the deficient practice does not recur the Human Resources supervisor was re-educated by the Nursing Home Administrator on the CHRC policy regarding determination letters and supervisor tracking forms for new hires while waiting for CHRC determination letters. The Human Resource supervisor will bring all new hire employee files to the Nursing Home Administrator for review, approval, and signature. The Administrator will report CHRC issues to the QA Committee monthly. This will be an ongoing process.
The person responsible for compliance is the Human Resource Supervisor.

E3BP 402.6(b):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. ...... (b) A provider requesting a criminal history record check pursuant to this Part shall do so by completing and submitting a form developed and provided by the Department after consultation with the Division and transmitting two sets of fingerprints to the Department. An authorized person, and only an authorized person, shall complete such form and shall submit the original with the authorized person signature (not a facsimile signature) and two sets of fingerprints to the Department not more than ten days (excluding Saturdays, Sundays and legal holidays) after taking the fingerprints of the prospective employee. The Department shall maintain such form, in the form and format prescribed by the Department, which: (1) identifies the name of each person for whom the provider requests a criminal record check, and attests that each such person is a prospective employee of the provider, and, as such, the person is a subject individual, as defined in this Part; (2) identifies the specific duties of the subject individual which qualify the provider to request a check of the subject individual's criminal history information; (3) attests that the results of the criminal history record check will be used by the provider solely for the purposes authorized by law; and (4) attests that the provider, its agents, and employees are aware of and will abide by the confidentiality requirements and all other provisions of Public Health Law Article 28-E and Executive Law section 845-b, as they may from time to time be amended.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: June 9, 2017
Corrected date: July 7, 2017

Citation Details

Based on interview and record review during the Standard survey completed on 6/9/17, the facility did not ensure that the Authorized Person completed the required Criminal History Record Check (CHRC) consent form for employees that were hired in the last four months. This affected four of four employee files reviewed for CHRC compliance. The finding is: 1. Review of employee files for four employees that were hired during the last four months (Certified Nurse Aides) for compliance with CHRC requirements revealed the Acknowledgement and Consent Forms for Fingerprinting and Disclosure of Criminal History Record Information (DOH CHRC 102) were incomplete. Further review of the consent forms revealed Section 3, titled Agency Authorized Person Information on each consent form was blank and did not include the agency name, the Authorized Person's name, signature, and title, the Permanent Facility Identifier (PFI) or Operating License Number, and the date the form was completed. Interview with the Human Resources Manager (Authorized Person) on 6/6/17 at approximately 3:10 PM revealed she has been an Authorized Person for less than one year and she was not trained to fill out Section 3 of the consent form. Per Part 402 - Criminal History Record Check; A provider requesting a criminal history record check pursuant to this Part shall do so by completing and submitting a form developed and provided by the Department after consultation with the Division and transmitting two sets of fingerprints to the Department. An authorized person, and only an authorized person, shall complete such form and shall submit the original with the authorized person's signature (not a facsimile signature) and two sets of fingerprints to the Department not more than ten days (excluding Saturdays, Sundays and legal holidays) after taking the fingerprints of the prospective employee. The Department shall maintain such form, in the form and format prescribed by the Department 402.6 (b)

Plan of Correction: ApprovedJuly 17, 2017

The facility will ensure the Criminal History Check Consent form (DOH CHRC 102)is completed and signed by an authorized person.
The facility recognizes that all residents have the potential to be affected by this deficient practice.
As immediate action the Human Resource supervisor conducted a 100% audit of all current employee files for completed CHRC 102 forms. Those employee files found incomplete were completed and signed by an authorized person, the Human Resource supervisor.
To ensure the deficient practice does not recur the Human Resource supervisor was educated by the Nursing Home Administrator on the CHRC policy and the completion of form 102.
Human Resource supervisor will bring all new hire employee files to the Nursing Home Administrator for review, approval, and signature. The administrator will report any CHRC issues to the QA Committee monthly. This process will be ongoing.
The person responsible for compliance is the Human Resource Supervisor.

ZT1N 415.17:DENTAL SERVICES

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interview during the Standard survey completed 6/9/17, the facility did not ensure that each resident receives a complete oral examination, by a licensed and currently registered Dentist or Dental Hygienist, within 7 days following completion of the initial comprehensive assessment. Two (Residents #33, 41) of three residents reviewed for dental services did not receive an initial dental examination within 21 days after admission. The findings are: 1. Resident #33 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/5/17 revealed the resident is cognitively intact. Observation of the resident on 6/8/17 at 10:00 AM revealed there were multiple missing teeth on both the upper and lower jaw. Interview with the resident at that time revealed she had 14 teeth extracted last year. The resident stated that she can get by chewing with what she has. Review of Dental Evaluation and Care Notes revealed the resident was first seen by the Dentist on 4/25/17. The Dental Evaluation documented that the patient was not having any discomfort, she stated she had cavities, and also had tartar on her teeth. Dental recommendations were to have the resident's teeth brushed before dental exams and to have a cleaning with the hygienist. The Evaluation documented caries (cavities) found - will do fills. Interview with the Director of Nursing (DON) and the Unit Secretary on 6/8/17 at 8:10 AM revealed We called the dentist in the first 48 hours of admission to set up the appointment. The Dentist schedules them for the initial visit. Review of a facility policy and procedure entitled Dental Scheduling for Long Term Elders dated 2/2017 revealed it is the collaborative responsibility of the long term care Resident Care Coordinator (RCC), unit secretaries, and dental schedulers to set up appointments in a timely manner for newly admitted LTC (Long Term Care) elders and to ensure annual dental examinations, routine and/ or emergency care as follows: All elders will receive a comprehensive examination by a licensed and registered NYS (New York State) Dentist or Dental Hygienist, within 14 days of admission and annually thereafter. The resident was first seen by the Dentist 40 days after admission and had oral issues that needed to be addressed. 2. Resident #41 was admitted on [DATE] and has [DIAGNOSES REDACTED]. Review of the MDS dated [DATE] revealed the resident has moderate cognitive impairment. Observation on 6/6/17 at 10:38 AM revealed the resident had chipped and missing teeth that were a dark tan color. Review of a Dental Evaluation and Care Note dated 9/19/16 revealed the resident was a new patient and presented with a broken fill #9 tooth. The Evaluation documented Patient states he doesn't want the tooth out. We will fill here and see how it goes. Plan to fill on 9/28/17. Interview with the resident on 6/9/17 at 9:15 AM revealed he has 12 missing teeth. The resident stated that he used to go to the dentist all the time, before he was admitted to the facility. As far as chewing, he does the best he can with the teeth he has. During an interview on 6/8/17 at 1:00 PM, the Resident Care Coordinator (RCC) Licensed Practical Nurse (LPN) stated We are supposed to get them on the dental list when they are first admitted . The problem probably lies with both parties, the nursing facility making prompt appointments and the resident actually seeing the dentist. He is usually here every day but he sees people from the community as well. He is out for surgery now and there is a replacement Dentist, but he will only be here one day a week. Interview with the Social Worker (SW) on 6/8/17 at approximately 11:00 AM revealed she wasn't aware that residents should be seen by the dentist upon admission and thought they were seen only if they had a probelm. The resident was first seen by the Dentist 92 days after admission and was identified with oral issues that needed to be addressed. 415.17(c)

Plan of Correction: ApprovedJune 28, 2017

The facility will ensure each resident receives a complete oral examination by a licensed and currently registered dentist or dental hygienist within twenty-one (21) days after admission and annually thereafter.
All residents have the potential to be affected by this deficient practice.
Immediate corrective action taken to address any oral issues identified is Resident #33 had follow-up dental visits on 5/5/17; 5/17/17;and 6/2/17. Her next scheduled appointment is on 7/19/17. The RCC ensures Resident #33's teeth are brushed prior to the dental visit. Resident #41 had follow-up dental visits on 3/29/17; 4/6/17; and 5/8/17. His next scheduled visit is on 8/30/17.
To ensure other residents have not been affected by this deficient practice the Director of Nursing or designee will audit all residents admitted in the past three months to ensure a complete oral examination was completed by the dentist or hygienist within 21 days of admission.
To ensure the deficient practice does not recur the policy Dental Scheduling for Long Term Elders was revised and the social worker; nurses; unit secretaries; and dental clinic staff will be educated by the education manager that a complete oral examination by a dentist or dental hygienist must be done within 21 days of admission and annually thereafter. In the event the Cuba Memorial Hospital dental clinic dentist or dental hygienist cannot schedule the resident within 21 days of admission, the resident will be scheduled for complete oral examination at the Olean General Hospital dental clinic. To further ensure the deficient practice does not recur, the Director of Nursing or designee will review monthly for a six months or until 100% compliance is achieved, all new admissions to ensure they have had or have been scheduled for a complete oral examination within 21 days of admission and that any oral issues are addressed. Findings will be reported by the Director of Nursing to the QA Committee on a quarterly basis to determine if compliance has been achieved.
The person responsible for compliance is the Director of Nursing.

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: June 9, 2017
Corrected date: August 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review conducted during the Standard survey completed on 6/9/17, the facility did not ensure that each resident's medication regimen was free from unnecessary medications. One (Resident #9) of three residents reviewed for unnecessary medications had issues involving the lack of documented evidence of behaviors to support the need to initiate the use of an antipsychotic medication ([MEDICATION NAME]) and the lack of implementation of non-pharmacological interventions before prescribing [MEDICATION NAME]. The finding is: 1. Resident #9 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 4/26/17 revealed the resident has severe cognitive impairment. Review of physician's orders [REDACTED]. Review of a physician's 60 Day Follow-Up Visit note dated 5/18/17 revealed the resident was declining physically and mentally and at times becomes psychotic. The resident says that she is going to be sent to Russia. The Physician documented a plan to begin [MEDICATION NAME] at nighttime that may help her sleep as well as calm her mind. Review of Interdisciplinary Progress Notes dated 3/15/17 through 5/18/17 revealed no documented evidence of behaviors, including hallucinations, delusions,paranoia, or [MEDICAL CONDITION], to support the need for daily antipsychotic medication. Review of the current Comprehensive Care Plan revealed there was no documentation regarding the use of an antipsychotic medication or that behavioral interventions were identified. Interview with the Licensed Practical Nurse (LPN #1) Resident Care Coordinator (RCC) on 6/6/17 at 2:00 PM revealed the RCC asked the Physician to evaluate the resident's medications because staff told her that the resident was having paranoid like behaviors. During an interview on 6/8/17 at 8:00 AM, the Director of Nursing (DON) stated that all resident behaviors are to be documented in the medical record. When a behavior is present, the staff is to provide one-to-one, offer care such as toileting or a drink and evaluate the resident for any signs or symptoms of illness or change and then document this. The DON reviewed the resident's medical record and stated the resident received [MEDICATION NAME] daily since 5/18/17 and the record did not have documentation of paranoid behaviors from 4/1/17 through 5/18/17. Review of Interdisciplinary Progress Notes dated 3/15/17 through 5/18/17 revealed there was one entry regarding behaviors dated 3/24/17 at 10:01 PM. The 3/24/17 Progress Note documented Resident yelling at staff to clean her glasses. After glasses were cleaned the resident continued to yell help me claiming her shirt was wet despite the shirt noted to be dry. Resident was placed in bed and resting with eyes closed. During an interview on 6/8/17 at 8:53 AM, the LPN RCC stated the medication nurses are to monitor the resident's behavior every shift and initial as done on the Behavior Monitoring Log. If any behaviors are noted, there is to be an entry placed in the Nurse's Notes regarding which behavior was noted; what the staff did to respond to that behavior; and the resident's response. The LPN RCC reviewed the Behavior Monitoring Logs dated 4/1/17 through 5/18/17 and stated that the nurses' circled verbal behaviors including requests for attention, questions, talkativeness and repetitive sentences on 35 out of 48 days. The Interdisciplinary Progress Notes dated 4/1/17 through 5/18/17 lacked documentation of behaviors for the resident during that time. The LPN RCC stated I assumed that the staff had documented behaviors and charted this in the resident's Progress Notes. They are to chart the specific behavior at each occurrence, the non-pharmacological interventions the staff did such as one to one or toileting and its effect on calming the patient. I was asked to talk to the physician at rounds about her increased paranoid behaviors. I did not review the resident's record prior to speaking to the Physician and I should have. Verbal behaviors including requests for attention, questions, talkativeness and repetitive sentences are not paranoid behavior. During an interview on 6/8/17 at 10:15 AM, the resident's Physician stated When a patient is agitated verbally or physically, the nurses should be approaching the resident, offering care and documenting the response to this intervention. If this is a pattern, the nurse should assess the resident to assure there is not a fecal impaction (constipation) or signs and symptoms of a urinary tract infection [MEDICAL CONDITION]. This should be monitored and documented for five days prior to approaching me for a pharmacological intervention unless there is a risk for physical harm to the resident or others. I am assuming they have done this when I am asked for intervention. Review of a Urine Culture Microbiology Report dated 5/20/17 revealed a urine specimen was obtained on 5/19/17 which showed greater than 100,000 CFU/ML of Proteus Species (bacteria). A hand written note on the Report dated 5/21/17 documented that the urine C&S report was noted on 5/21/17 and the resident was currently receiving [MEDICATION NAME] (antibiotic) 500 milligrams twice a day for a UTI (ordered 5/19/17). Review of an Interdisciplinary Progress note dated 6/6/17 at 1:02 AM revealed the resident was alert and cooperative with staff and continued to receive [MEDICATION NAME]. 415.12(l)(1)

Plan of Correction: ApprovedJuly 12, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will ensure each residents' medication regimen is free from unnecessary medications. all residents have the potential to be affected by this deficient practice.
Immediate corrective action taken was the Director of Nursing reviewed Resident #9's medical record and comprehensive care plan. The physician was notified to determine if resident needed to continue the antipsychotic medication. The physician continued the antipsychotic medication. On 6/14/17 the resident was transferred to the hospital for acute abdominal pain, nausea/vomiting and under went surgery. It was determined that the resident had a wide spread, untreatable malignancy. The resident returned to the facility on [DATE]. The physician order [REDACTED].
To ensure other residents have not been affected by this deficient practice a 100% audit of all current residents with prescribed routine and PRN antipsychotic medications will be reviewed by the Director of Nursing to ensure there is documented evidence of behaviors to support the use of an antipsychotic drug; documented implementation of non-pharmacological interventions; resident response to these interventions; and the need to continue the antipsychotic medication. The DON will bring the Behavior monitor logs and nurse progress notes to the Interdisciplinary Care Plan Meeting and the IDT will review the comprehensive care plans and update it to reflect the residents' current behaviors, interventions, and responses. A new systemic process has been implemented to track new [MEDICAL CONDITION] medication orders. This tracking form will be reviewed with the interdisciplinary team at morning meeting. This will be an ongoing process. The physician will review current residents with orders for antipsychotic medication to determine the need to continue this medication.
To ensure the deficient practice does not recur, the education manager will provide education to licensed staff on the need to document resident behaviors, implementation of non-pharmacological interventions, and resident response to the intervention on the behavior monitor log, nurses notes, and in the care plan. The education manager will also educate all nursing staff on resident behaviors, assessing for unmet needs (toileting, hunger, thirst, boredom, etc.) and implementing non-pharmacological interventions to manage behaviors. The social worker monitors residents on [MEDICAL CONDITION] medications for signs/symptoms of emotional distress and changes in mood and/or behavior. The interdisciplinary team will review the consultant pharmacist's Psychoactive Utilization Trend Report and the Psychoactive Utilization by Resident Report once a month. The consultant pharmacist and the Medical Director or designee will participate in this meeting either in person or via conference call. This will be an ongoing process.
The DON or designee will audit all residents' with routine and PRN antipsychotic medications each month to ensure proper initiation, interventions, and documented continued evidence of behaviors to support the use of the medication. This will include review of behavior monitor logs, nurses notes, and comprehensive care plans. The DON will report the findings of this audit monthly to the Quality Assurance Committee. The QA Committee will ensure the corrective action is maintained by determining there is a decrease in utilization of psychoactive medications and increased effectiveness of documented interventions. This process will be ongoing.
The person responsible for compliance is the Director of Nursing.

FF10 483.90(d)(2)(e):ESSENTIAL EQUIPMENT, SAFE OPERATING CONDITION

REGULATION: (d)(2) Maintain all mechanical, electrical, and patient care equipment in safe operating condition. (e) Resident Rooms Resident rooms must be designed and equipped for adequate nursing care, comfort, and privacy of residents.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation, interview, and record review during the Standard survey completed on 6/9/17, the facility did not maintain all essential mechanical, electrical and patient care equipment in safe operating condition. Issues involved the lack of an annual inspection of the facility's domestic water supply backflow prevention devices, the lack of backflow prevention on the dishwashing machine, and the food preparation sink drain was not maintained to prevent cross contamination. This affected three (First, Second, Third Floors) of three resident use floors and one of one Basement. The findings are: 1. Review of the Report on Test and Maintenance of Backflow Prevention Device revealed three backflow prevention devices for the facility's domestic water supply were tested by an outside contractor on 2/15/15. Further review revealed this was an annual test. Interview with the Maintenance Supervisor on 6/6/17 at approximately 2:10 PM revealed he had no documentation that an annual test had been conducted since 2/15/15. 2. Observation in the Main Kitchen on 6/5/17 at approximately 9:25 AM revealed the drain to the dishwashing machine was a two-inch diameter accordion-style flexible hose that extended approximately six inches down into a nearby floor drain, which provided a potential cross connection between the dishwashing machine and the sewage system floor drain plumbing Interview with the Food Service Director at the time of the observation revealed this was a new dishwashing machine that was installed approximately six to eight months ago. Interview with the Maintenance Supervisor on 6/7/17 at approximately 10:48 AM revealed the dishwashing machine was installed by an outside contractor. The Maintenance Supervisor further stated if the floor drain backed up, sewage could enter the drain hose of the dishwashing machine, and he is not certain if the dishwashing machine is equipped with a check valve (one-way directional valve) to prevent sewage from entering the machine. 3. Observation in the Main Kitchen on 6/6/17 at approximately 10:40 AM revealed the indirect drain on the food preparation sink was not maintained to prevent cross contamination. Further observation revealed the downspout of the sink measured approximately two inches in diameter and the funnel for the sewer plumbing measured approximately two and one quarter inches in diameter and the downspout of the sink extended into the funnel for an undetermined distance, which provided a potential cross connection between the sink drain and the sewage system plumbing. Interview with the Food Service Director at the time of the observation revealed this sink is used for the washing of fruits and vegetables. Interview with the Maintenance Supervisor on 6/7/17 at approximately 10:45 AM revealed he was not aware of the requirement for an indirect drain on a food preparation sink. 415.14(h) 415.29(f)(4) 14-1.40, 14-1.140, 14-1.141

Plan of Correction: ApprovedJuly 17, 2017

The facility will ensure all essential mechanical, electrical, and patient care equipment is maintained in safe operating condition. All residents have the potential to be affected by this deficient practice.
As corrective action, The contractor was contacted immediately and they conducted an inspection of the facility's three domestic water supply backflow prevention devices on 6/9/17. The manufacturer of the new dishwasher verified that the machine is equipped with a one-way directional valve to prevent sewerage from entering the machine. On 6/28/17 an indirect drain was installed on the food preparation sink to prevent cross contamination.
To ensure the deficient practice does not recur the maintenance supervisor will ensure the outside contractor conducts an annual inspection of the facility's domestic water supply backflow prevention devices and will maintain documentation that the annual testing has been done. The maintenance supervisor will report that the testing was done annually at the Safety Committee.
The Maintenance Supervisor is responsible for compliance.

FF10 483.10(g)(14):NOTIFY OF CHANGES (INJURY/DECLINE/ROOM, ETC)

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a Complaint Investigation (Complaint #NY 162) during the Standard survey completed on 6/9/17, the facility did not immediately inform the resident's legal representative or an interested family member when there was a change in the resident's physical, mental, or psychosocial status and a need to alter treatment. Specifically, one (Resident #16) of two residents reviewed for notification of change had an issue involving the lack of notification of the resident's responsible party when the resident developed a pressure ulcer. The finding is: 1. Resident #16 has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 3/1/17 revealed the resident was moderately cognitively impaired and was understood and understands. Review of a senior care six month assessment dated [DATE] revealed under the assessment and plan section, pressure ulcer of the thigh: Right lateral thigh, Stage II, covered with DuoDerm and will refer to wound clinic for management. Review of E-Z Graph Wound Assessment Worksheet dated 3/8/17 revealed upper right hip open area, Stage 3, 2 areas, 1) 1.4 x 1.4 x 0.2 cm (centimeters), 2) 1.2 x 1.1 x0.1 cm, both areas covered with yellow slough (soft, moist, dead tissue), eschar (black or brown dead tissue) area 1.2 x 1.2 cm, gray in color, scant amount of bloody drainage noted. Review of physician's orders [REDACTED]. Change daily and as needed if soiled. Review of the Nursing Progress Notes dated 2/24/17 through 3/24/17 revealed no documentation that the resident's Health Care Proxy (HCP) was notified of the two Stage 3 pressure ulcers on the upper right hip. On 6/8/17 at approximately 9:07 AM the Licensed Practical Nurse (LPN #1) Resident Care Coordinator (RCC) stated The area on the right upper hip I guess could have been both a scratch and pressure, right? I am thinking it was pressure ulcer because of the size area. I think that is why I have it marked on the wound assessment as both. The area on the upper right hip at first we thought it was a scratch as the resident had scabies and was badly itching and digging at herself. After looking at it closer the area had slough, a greenish cover film and a black spot on it. Wound rounds are done by me and a Registered Nurse (RN) and we both do the assessing together. On 6/8/17 at approximately 9:22 AM the Director of Nursing (DON) stated Originally we thought it was a scratch on the hip and when went in to look at it, we determined it to be a Stage 3 pressure ulcer. When we assess residents for skin issues there is always an RN going with LPN #1. LPN #1 is a wound specialist, but she is only an LPN and the residents need to be assessed by an RN. If I am off on the day of wound rounds, the RN Supervisor will go with her to do the assessments. On 6/8/17 at approximately 11:14 AM the DON stated The family and senior care were both notified of the Stage 3 pressure areas on the resident's upper right hip. They are always notified. We would document it in the Nurses' Notes that they were notified, I do not know why it wasn't documented. We were not the ones that found the pressure area on the hip, it was senior care that found it. She was sent to senior care and she came back to us with a DuoDerm (moisture retentive wound dressing) on her upper right hip. When speaking to senior care, they told us that they contacted the daughter, but I do not have any documentation showing that they spoke to the daughter or that we spoke to the daughter. Review of Policy and Procedure titled Change in Condition or Status dated 4/17/16 reveals: Unless otherwise instructed by the patient/ elder, the Supervisor/ Charge Nurse will notify the patient's/ elder's next of kin or responsible party when: there is a significant change in the patient's/ elder's physical, mental, or psychosocial status. 415.3(e)(2)(ii)(b)(c)

Plan of Correction: ApprovedJuly 7, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will ensure that the resident's responsible party or family member is notified when there is a change in the resident's physical, mental, or psychological status and there is a need to alter treatment.
As immediate corrective action Resident #16's medical record was reviewed by the Director of Nursing (DON). The resident was transferred to the hospital on [DATE] and the PACE program confirmed that it was not a bed hold. The resident did not return to the facility. The facility collaborated with the PACE program to ensure improved communication between the facility and the PACE program and that family notification occurs when there is a change in resident's condition. The plan to improve communication includes the PACE program provided case manager names and contact information to the facility, facility staff attends the resident's PACE case management meeting by phone or in person, and the PACE program staff is invited to attend the resident's interdisciplinary care plan meeting at the facility or via conference call.
To identify other residents that may have been affected by this deficient practice the DON will review all nursing progress notes and skin assessments of current residents with pressure ulcers to determine whether the resident's responsible party or family member has been notified that a pressure ulcer developed or there is an need to alter treatment. This notification will include any off site services.
The education manager will provide inservice education to all nurses on the need to notify resident's responsible party or family member when there is a change in the resident's physical, mental, or psychological status and/or there is a need to alter treatment and document this notification in the medical record. The inservice will include a review of the facility's Change in Condition or Status policy and procedure, which has been revised to reflect notification of off site services, as well as family or responsible party, and documentation in the medical record that notification occurred.
To ensure the deficient practice does not recur the Director of Nursing will conduct a monthly audit of residents with pressure ulcers to ensure the resident's responsible party or family member and off site services were notified of a change in condition or the need to alter treatment. Audit results will be reported by the DON to the Quality Assurance Committee quarterly to determine if compliance has been achieved and maintained. This will be an ongoing process.
The person responsible for compliance is the Director of Nursing.

FF10 483.75(g)(1)(i)-(iii)(2)(i)(ii)(h)(i):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: (g) Quality assessment and assurance. (1) A facility must maintain a quality assessment and assurance committee consisting at a minimum of: (i) The director of nursing services; (ii) The Medical Director or his/her designee; (iii) At least three other members of the facility's staff, at least one of who must be the administrator, owner, a board member or other individual in a leadership role; and (g)(2) The quality assessment and assurance committee must : (i) Meet at least quarterly and as needed to coordinate and evaluate activities such as identifying issues with respect to which quality assessment and assurance activities are necessary; and (ii) Develop and implement appropriate plans of action to correct identified quality deficiencies; (h) Disclosure of information. A State or the Secretary may not require disclosure of the records of such committee except in so far as such disclosure is related to the compliance of such committee with the requirements of this section. (i) Sanctions. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

Based on observation, interview, and record review conducted during the Standard survey completed 6/9/17, the facility did not ensure that the Quality Assessment and Assurance (QAA) committee must develop and implemented appropriate plans of action to correct identified quality deficiencies. Specifically, the facility QAA committee did not implement an appropriate plan of action to correct ongoing concerns of inadequate Registered Nurse (RN) staffing for the hospital based skilled nursing facility (SNF). The facility did not ensure that there was a RN scheduled for eight consecutive hours per day, seven days a week. In addition, the facility did not ensure that the designated RN Director of Nursing (DON) worked consistently on a full-time basis. This issue involved two of two resident care units. In addition the facility did not ensure that the QAA committee identified and corrected quality of care deficiencies identified during the recertification survey completed on 5/6/16. The findings are: 1. Refer to F354 - Waiver RN staffing 8 hours a day 7 days a week, full time. Severity = F Review of the approved Plan of Correction (P(NAME)) for the Standard survey completed 5/6/16 revealed the facility identified a correction date of 5/26/16 related to deficient practices cited under F354. Further review of the P(NAME) revealed, the daily/monthly schedules will be reviewed/reported to the QA committee quarterly. The person responsible for compliance is the Nursing Home Administrator. Review of the DON's timesheets from 12/25/16 through 6/10/17 revealed that the DON worked full time hours (35 hours per week or more) eight weeks out of 24 weeks. Interview with the Acting Administrator on 6/5/17 at approximately 9:15 AM revealed the DON was out sick. Interview with the Acting Administrator on 6/6/17 at approximately 10:00 AM revealed the DON was out sick and needed to get a physician's note to come back to work. Interview with the Acting Administrator on 6/8/17 at approximately 10:50 AM revealed that one of the Registered Nurses (RN) from the hospital is the acting DON when the DON is out of. Interview with the hospital RN #4 on 6/8/17 at approximately 11:18 AM revealed that she was not aware that she would be the acting DON when the DON was not in the facility (skilled nursing). Interview with the DON on 6/8/17 at approximately 11:53 AM revealed that she cannot work eight hours a day, 40 hours a week and that is why she resigned last week. Interview with the Acting Administrator on 6/8/17 at approximately 1:00 PM revealed that she was not aware that the DON resigned. Interview with the Acting Administrator on 6/9/17 at approximately 10:30 AM revealed the DON she has placed adds to hire a new Director of Nursing (DON) for the Skilled Nursing Facility. Review of the timesheets for the RN's scheduled to work in the hospital and the SNF between 12/25/16 through 6/10/17 revealed that there was no RN coverage for eight consecutive hours on 12/25/16, 1/21/17, 1/22/17, 2/8/17, 2/9/17, 2/14/17, 217/17, 2/22/17, 2/23/17, 3/2/17, 3/4/17, 3/5/17, 3/21/17, 3/23/17, 3/28/17, 4/5/17, 5/1/17, 5/14/17, 5/22/17, 5/27/17, and 5/31/17. In addition, there were zero hours of RN coverage in the SNF on 2/8/17, 2/23/17, 3/2/17, 3/4/17, 3/5/17, and 3/21/17. Review of the Facility Survey Report signed by the Acting Administrator dated 6/8/17 revealed the QAA committee last met 4/25/17. 415.27(c)(v)

Plan of Correction: ApprovedJuly 17, 2017

This plan demonstrates the facility's desire to comply with the regulations and continue to provide quality care.
F520 - QAA Committee-Members/meet quarterly/plans DP(NAME):
Assessment of causative factors that may have contributed to the issues identified in the deficiency:
*Three (one RN per shift) full-time RN vacant positions for 2 years with no applicants or inadequate candidates.
*Staff absenteeism: RCC (staffing coordinator) had no one to cover open position; DON filled in for LPN/RN call offs; LPN filled in for CNA call offs; and lack of communication between RCC, DON, and NHA.
*Lack of RNs available due to medical leave, FMLA, resignation, no applicants and lack of adequate candidates.
*DON gave resignation to Human Resources supervisor. DON and HR supervisor failed to notify NHA.
*DON worked weekends and off shift to cover open positions then was unable to fulfill required DON schedule.
Lack of communication between RCC and DON regarding schedule and vacancies.
The interventions undertaken to eliminate and correct the causative factors identified:
*Human Resources supervisor will meet twice a month with the RCC, DON, and NHA to review vacancies, extended leaves, FMLA, resignations ,workers compensation, and attendance issues.
*RCC will attend job fairs to enhance recruitment efforts.
*Collaborate with CNA training class providers.
*DON will not work as a staff nurse except in an emergency when census is below 60.
*DON will review and approve staffing schedules prior to posting.
*Hired full-time RN to cover off shift hours of 8PM to 8AM (giving eight consecutive hours from 12MN to 8AM). DON will cover for RN eight consecutive hours in an emergency when census is below 60.
*Redesigned daily staffing sheet to identify RN staffing.
*Hired full-time Director of Nursing to work Monday through Friday, 8AM to 4PM. Start date 7/10/17.
*Facility designated a full-time RN as the Acting Director of Nursing from 6/23/17 to 7/10/17.
*DON schedule will be Monday through Friday, 8AM to 4PM.
For circumstances requiring DON to cover vacant RN shifts, this will only occur when all other efforts have been exhausted and the census is below 60.
The triggers identified that will signal all staff of an evolving problem or deficient practice situation:
*Human Resources supervisor meeting two times per month with the NHA, DON, and RCC to identify vacancies, turnover rates, extended leaves, and attendance issues will trigger the identification of a problem and a need to develop a plan of action.
The facility will measure whether efforts are successful or unsuccessful in maintaining compliance by:
*Based on meetings with HR supervisor, NHA, DON, and RCC to improve communication regarding the identification of staffing needs.
*Review of submitted report of turnover rates, vacancies, and extended leaves by the DON and NHA for reporting to the QA Committee quarterly.
*Increased RN staffing with recruitment efforts.
*RN will work eight consecutive hours per day, seven days per week.
*DON works full-time hours Monday through Friday, 8AM to 4PM.
*Improved quality of care.
*Improved systems management.
The facility will ensure the QA Committee develops and implements appropriate plans of action to correct identified quality deficiencies.
All residents are potentially affected by this deficient practice.
As immediate corrective action the QA Committee convened on 6/27/17. A directed plan of correction was conducted by the consultant to identify the root cause and develop a plan of action to correct ongoing concerns of inadequate RN staffing, to ensure an RN is scheduled 8 consecutive hours per day, 7 days per week, and the DON works consistently on a full-time basis. Also, the QA committee assessed the causative factors related to the QA team and the NHA not reviewing and reporting the ongoing RN staffing and DON hours concerns or developing an appropriate action plan to correct the deficient practice. Causative factors identified were: QA team lacked knowledge about the QA process; QA committee meeting had been changed from monthly to quarterly; and inconsistent Nursing Home Administrators. The interventions undertaken to correct the causative factors identified:
*Quality assurance will be converted to a Quality Assurance and Performance Improvement process (QAPI)
*Consultant will provide education on the QAPI process to the QA team
*Nursing Home Administrator hired 6/26/17 to provide consistent leadership
*QA Committee meetings changed from quarterly to monthly to ensure action plans are implemented and effective
Outcomes will be measured by the QA Committee reviewing monthly staffing reports to ensure RN coverage 8 hours per day/7 days per week and full time hours are worked by the DON. Quality indicators, complaints, incident reports, hospitalization s, and infection rates will be reviewed each month. Staff vacancies are reported to the Board of Trustees monthly and the BOT approves the budget related to new hires. The Board of Trustees will review the QA Committee minutes monthly to ensure action plans are implemented and the process is sustainable.
The triggers identified that will signal all staff that the QA process is not working is an increase in incidents; increase in hospitalization s, increase in infection rates, and increase in complaints.
To ensure the deficient practice does not recur the NHA will review and approve the DON's schedule to ensure full time hours are worked weekly. The DON will review, approve, and sign off on the RN schedules prior to posting to ensure an RN works 8 consecutive hours per day/7 days per week. In the event of extended leaves, a temporary person will be hired into the vacant position. In the event of a call-in, the staff member working will be mandated to stay if replacement coverage can not be obtained. A new policy has been developed to ensure RN coverage meets the regulations. All licensed nursing staff will be educated on the new policy. The Human Resource policy titled Employment Termination has been reviewed and revised to ensure leadership position resignations are given directly to their Director. The DON and ADON will be educated on this policy. In the event the DON is unavailable, the facility has designated an RN as the ADON, who will act as the DON in her absence. All staff has been notified of this designation. The QA Committee will meet monthly to identify any triggers or evolving problems and develop and implement an action plan. The HR supervisor will submit a monthly report to the NHA and DON which includes turnover rates, vacancies, extended leaves, and attendance issues. This report will be reviewed at the monthly QA committee meeting for three months or until the QA Committee deems 100% compliance has been obtained. A systemic change has been implemented to ensure there is accurate tracking of identified triggers. The tracking log will be reviewed with the interdisciplinary team at morning report Monday through Friday to ensure appropriate action plans are implemented if a trigger signals a problem is evolving.
Responsible person: Nursing Home Administrator

FF10 483.35(b)(1)-(3):WAIVER-RN 8 HRS 7 DAYS/WK, FULL-TIME DON

REGULATION: (1) Except when waived under paragraph (e) or (f) of this section, the facility must use the services of a registered nurse for at least 8 consecutive hours a day, 7 days a week. (2) Except when waived under paragraph (e) or (f) of this section, the facility must designate a registered nurse to serve as the director of nursing on a full time basis. (3) The director of nursing may serve as a charge nurse only when the facility has an average daily occupancy of 60 or fewer residents.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

Based on observation, interview, and record review conducted during the Standard survey completed on 6/9/17, the facility did not ensure that there was a Registered Professional Nurse (RN) scheduled for eight consecutive hours per day, seven days a week. In addition, the facility did not ensure that an RN was designated as the Director of Nursing (DON) on a full-time basis. The finding is: 1. Review of an undated list of RN's working in the facility revealed that there are four RN's plus an RN Minimum Data Set (MDS - a resident assessment tool) Coordinator who had worked full time until (MONTH) (YEAR). During an interview on 6/8/17 at approximately 10:50 AM, the Acting Administrator stated that the facility schedules an RN in the skilled nursing facility (SNF) eight hours per day. The Acting Administrator further stated that if an RN from the hospital were to be scheduled to work in the SNF they have to punch out of the hospital on their time card and punch into the SNF. Review of timesheets for the RN's scheduled to work in the hospital and SNF between 12/25/16 through 6/10/17 revealed that there was no RN coverage for eight consecutive hours on 12/25/16, 1/21/17, 1/22/17, 2/8/17, 2/9/17, 2/14/17, 217/17, 2/22/17, 2/23/17, 3/2/17, 3/4/17, 3/5/17, 3/21/17, 3/23/17, 3/28/17, 4/5/17, 5/1/17, 5/14/17, 5/22/17, 5/27/17, and 5/31/17. In addition, there were zero hours of RN coverage in the SNF on 2/8/17, 2/23/17, 3/2/17, 3/4/17, 3/5/17, and 3/21/17. Interview with RN #3 on 6/9/17 at approximately 10:39 AM revealed that the hospital Nursing Supervisor is available if an RN assessment is needed in the SNF. RN #3 was not aware that the hospital RN was required to punch out of the hospital and punch into the SNF. Interview with RN #2 on 6/9/17 at approximately 10:40 AM revealed that if an RN is scheduled for the hospital and is needed for an assessment or emergency in the SNF, they do not punch out of the hospital and then punch into the SNF. RN #2 stated, We don't punch into the SNF if there isn't an RN over there. Interview with the Acting Administrator on 6/9/17 at approximately 11:15 AM revealed she was not aware that RN's were not punching into the SNF when they came over to help. She stated that she did not tell staff to punch in and out for the SNF. The Administrator stated that hospital RN's work around their work in the hospital if they are needed in the SNF. However, they aren't going to be devoted to working in the SNF. 2. Interview with the Acting Administrator on 6/5/17 at approximately 9:30 AM revealed that the DON was not scheduled on 6/5/17. During an interview on 6/8/17 at approximately 10:50 AM, the Acting Administrator revealed that one of the hospital RN's is also the acting DON when the DON is out; staff know the acting DON is available to answer any of their questions. Interview with a Certified Nurse Aide (CNA #2) on 6/8/17 at approximately 10:58 AM revealed she did not know who the acting DON was on the days the DON was not available. Interview with Licensed Practical Nurse (LPN #3) on 6/8/17 at approximately 11:00 AM revealed she did not know who the acting DON was and thought it might be one of the hospital RN's. Interview with LPN #2 on 6/8/17 at approximately 11:00 AM revealed she did not know who the acting DON was on the days the DON was not available. LPN #2 added she had been instructed on 6/5/17 and 6/6/17 that if she needed an RN to call one of the RN's in the hospital. Interview with RN #4 on 6/8/17 at approximately 11:18 AM revealed she was not aware that she was the acting DON of the SNF when the DON was not in the facility. Review of the Director of Nursing's (DON) timesheets from 12/25/16 through 6/10/17 revealed the DON worked full time hours (35 hours per week or more) eight out of 24 weeks. Interview with the DON on 6/8/17 at approximately 11:50 AM revealed that she is not available to work eight hours a day, 40 hours a week, therefore, she resigned last week. Interview with the Acting Administrator on 6/8/17 at approximately 1:00 PM revealed she was not aware the DON resigned and stated that notice (of resignation) should be four weeks. The Acting Administrator stated one of the hospital RN's will be assigned as the acting DON of the SNF. Review of the undated facility Director of Nursing job description revealed that the DON is to provide administrative and clinical leadership and direction for nursing practice with 24-hour accountability on her/his nursing units. Under Work Environment Hazards revealed that the DON is subjected to long and irregular hours. 415.13(b)(1)

Plan of Correction: ApprovedJuly 13, 2017

The facility will ensure there is a Registered Professional Nurse (RN) scheduled for eight consecutive hours per day, seven days per week. The facility will also ensure that an RN is designated as the Director of Nursing (DON) on a full-time basis.
All residents have the potential to be affected by this deficient practice.
As immediate corrective action the full time RN's hours have been changed to 8:00PM to 8:00AM to ensure eight consecutive hours per day of RN coverage from 12MN to 8AM. The current Director of Nursing has resigned from her position on 6/23/17. A full time RN has been designated as the Acting Director of Nursing until 7/10/17 when the newly hired full time Director of Nursing begins her employment. All SNF staff have been notified of this information. Formal letters regarding the Acting and the new DON were mailed to DOH on 7/12/17. The Director of Nursing will review the daily staffing sheets to ensure there is an RN scheduled eight consecutive hours daily and if a vacancy exists an RN will be scheduled. The Nursing Home Administrator will review the Acting Director of Nursing's, as well as the new hire Director of Nursing's schedule to ensure full time hours are maintained. In the event of an extended leave an RN will be assigned or hired temporarily into the position.
To ensure this deficient practice does not recur, ads have been placed in local newspapers and on the indeed.com website for full time RNs. A full time Director of Nursing has been hired with a start date of 7/10/17. The Human Resource supervisor will educate hospital RNs that when they are assigned to work on SNF they are to punch out of their hospital unit and punch in on the SNF unit they are assigned to work. The daily staffing sheets have been revised to reflect the names of the DON or ADON and the RN Supervisor(s). This revised form will communicate to all SNF staff who the DON or ADON is and what RN Supervisor is on duty. A new policy titled RN Coverage for Long Term Care has been implemented. All nursing staff will be educated by the Nursing Home Administrator about the new policy, the revised daily staffing sheet and the requirement for an RN to work for eight consecutive hours per day, 7 days per week. Human Resource supervisor will notify the Nursing Home Administrator of any SNF employee's resignation,extended medical leave, or if time and attendance issues occur.
The DON will approve the daily nursing staff schedule to ensure there is an RN working eight consecutive hours per day/seven days per week prior to posting. The Nursing Home Administrator will review the DON's schedule to ensure full time hours are worked. This process will be ongoing. The QA Committee will review monthly staffing reports to ensure an RN works eight consecutive hours per day/ seven days per week and that the DON is working full time hours. This review will be done monthly for three months or until 100% compliance is attained. Thereafter, random audits will be done quarterly by the Human Resource/payroll supervisor and reviewed by the QA Committee for one year to ensure the corrective action plan is sustained.
The Nursing Home Administrator is responsible for compliance.

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

REGULATION: Aisle, Corridor or Ramp Width 2012 EXISTING The width of aisles or corridors (clear or unobstructed) serving as exit access shall be at least 4 feet and maintained to provide the convenient removal of nonambulatory patients on stretchers, except as modified by 19.2.3.4, exceptions 1-5. 19.2.3.4, 19.2.3.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: June 30, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview during the Life Safety Code survey completed on 6/9/17, means of egress corridors were not kept clear and unobstructed. Issues included, where the corridor width was at least eight feet wide, furniture reduced the corridor width to less than six feet and was not fixed in place, and wheeled, stored equipment reduced the clear unobstructed width of an exit access corridor to less than 60 inches. This affected two (Second, Third Floors) of three resident use floors and one of one Basement. The findings are: 1. Observation on the Second Floor on 6/5/17 at approximately 10:20 AM revealed one chair and one circular table were located within the means of egress, projecting into the required corridor width, across from the elevators. Further observation at this time revealed the chair and table restricted the nine foot wide corridor down to approximately six feet wide and they were not fixed to the floor or wall. 2. Observation on the Third Floor on 6/5/17 at approximately 10:35 AM revealed two chairs were located within the means of egress, projecting into the required corridor width, outside of Resident room [ROOM NUMBER]. Further observation at this time revealed the chairs restricted the eight foot wide corridor down to approximately five feet wide and they were not fixed to the floor or wall. 3. Observation on the Third Floor on 6/5/17 at approximately 11:00 AM revealed three chairs were located within the means of egress, projecting into the required corridor width, outside of Resident room [ROOM NUMBER]. Further observation at this time revealed two of the chairs (upholstered arm chair and upholstered desk chair) restricted the eight foot wide corridor down to approximately five feet wide and the third chair (leather recliner) restricted the corridor down to approximately four and a half feet wide. Additional observation revealed the chairs in this location were not fixed to the floor or wall. 4. Observation on the Third Floor on 6/5/17 at approximately 1:14 PM revealed two chairs and a table were located within the means of egress, projecting into the required corridor width, across from the elevators. Further observation at this time revealed the chairs and table restricted the nine foot wide corridor down to approximately six and a half feet wide and they were not fixed to the floor or wall. Interview with the Maintenance Supervisor on 6/7/17 at approximately 8:38 AM revealed this furniture is always kept in the corridor and it gets used throughout the day. 5. Observation in the Basement on 6/5/17 at approximately 1:40 PM revealed there was a six foot wide by 17 foot long exit access corridor inside the Laundry Room which was equipped with an illuminated exit sign. Further observation revealed this corridor was lined with full clean linen carts that restricted the clear corridor width down to approximately three and three quarters feet wide for the entire length of 17 feet. Interview with the Housekeeping Director at the time of the observation revealed the clean linen carts are delivered by an outside contractor twice per week, Monday and Thursday mornings, and the Monday morning delivery just arrived. Additional interview with the Housekeeping Director at this time revealed as the clean linen is used, the empty carts are moved to a different location of the Laundry Room. A second observation of the Laundry Room on 6/7/17 at approximately 2:54 PM revealed the same exit access corridor was lined with full clean linen carts. Interview with a Laundry Aide at the time of the second observation revealed the outside contractor's clean linen delivery will take place tomorrow morning, and this is about as empty as the Laundry Room will get before the next delivery. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2, 19.2.1, 19.2.3.4, 19.2.3.5

Plan of Correction: ApprovedJune 29, 2017

In order to protect the potentially affected residents on the second floor, third floor, and in the basement, the facility will ensure means of egress corridors are kept clear and unobstructed in accordance with NFPA 101.
All residents have the potential to be affected by this deficient practice.
Immediate corrective action taken for the second floor was to remove the table and chairs across from the elevators. Immediate corrective action for the third floor was to remove the table and chairs across from the elevators and remove the chairs outside rooms #303 and #300. Immediate action taken for the basement was to remove the clean linen carts from the laundry room exit access corridor. The linen vendor making deliveries will be educated by the Housekeeping manager on the new location (first floor West Main) for the clean linen carts and that egress corridors can not be obstructed.
To prevent this deficient practice from happening again, the education manager will re-educate all staff on the importance of keeping all egress corridors free from obstruction. The maintenance staff will conduct weekly rounds to ensure all egress corridors are free from obstruction. The Maintenance supervisor will report findings to the Safety Committee for three months or until 100% compliance is achieved.
The person responsible for compliance is the Maintenance supervisor.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/9/17, the facility's emergency generator was not connected to a remote alarm annunciator. This affected one of one emergency generator, that provided emergency back-up power to three (First, Second, Third Floors) of three resident use floors and the Basement and the automatic sprinkler system's fire pump. The finding is: 1. Observation in the Basement on 6/5/17 at approximately 2:05 PM revealed the facility's emergency generator was located inside the Generator Room, within the Maintenance Shop. Review of emergency generator logs on 6/6/17 revealed no written evidence that a remote annunciator was connected to the emergency generator. Interview with the Maintenance Supervisor on 6/7/17 at approximately 12:20 PM revealed the facility's emergency generator has never had a remote annunciator located anywhere in the building. According to the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, 2012 edition, a remote annunciator, that is storage battery powered, shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4.1.1.17

Plan of Correction: ApprovedJuly 21, 2017

K 916-In accordance with NFPA, Essential Electrical System Alarm Annunciator.
The facility will plan to have the emergency generator connected to a remote alarm annunciator 6/22/18. The facility has applied for a one year time limit waiver. The application was sent to BAER on 6/29/17. During the approval process maintenance staff will monitor that the emergency generator is operational and maintain a monthly log. The condition and the need for a one year time limit waiver, as well as the monthly generator tests, will be reported at the monthly QA Committee meetings.
This will be an ongoing process.
Responsible party: Maintenance supervisor

K307 NFPA 101:HAZARDOUS AREAS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: July 7, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/9/17, hazardous areas were not protected. Issues included doors to hazardous areas that did not self-close and latch into their door frames, a penetration through a hazardous area door, and a hazardous area door that was obstructed from closing. This affected one (Second Floor) of three resident use floors and one of one Basement. The findings are: 1. Observation on the Second Floor on 6/5/17 at approximately 9:40 AM revealed the door to the Clean Utility Room would not self-close and latch into its door frame. Interview with the Maintenance Supervisor on 6/5/17 at approximately 12:48 PM revealed the door hinge was loose and needed to be tightened. 2. Observation on the Second Floor on 6/5/17 at approximately 9:46 AM revealed the door to the Clean Linen Room had a one-third inch diameter penetration through it, near the door handle. 3. Observation in the Basement on 6/6/17 at approximately 8:15 AM revealed the door to the Medical Waste Room was obstructed from closing by a wooden door chock. Further observation at this same time revealed this room measured approximately 20 feet long by seven feet wide and contained three approximate 63-gallon trash totes, a compressor, the generator transfer switch, and a grill without a propane tank. Additional observations of the Medical Waste Room door being obstructed from closing were made on 6/6/17 at 1:15 PM and 6/7/17 at 10:00 AM 4. Observation in the Basement on 6/6/17 at approximately 11:00 AM revealed the door to the dishwashing area of the Kitchen would not self-close and latch into its door frame. Further observation revealed friction from the floor stopped the door from self-closing. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2, 19.3.2.1, 19.3.2.1.2, 19.3.2.1.3, 19.3.2.1.5

Plan of Correction: ApprovedJune 29, 2017

All residents have the potential to be affected by this deficient practice. To protect the potentially affected residents, the facility will ensure that hazardous areas are protected.
Immediate corrective action taken is on 6/5/17 the second floor clean utility room door hinge was tightened and the closure was adjusted so the door would self close and latch into its frame. On 6/5/17 the penetration near the door handle on the second floor clean utility room was repaired and the wooden door chock was removed from the medical waste room in the basement. On 6/26/17 the three hinges on the door to the dishwashing area of the kitchen were replaced and the door now self closes and latches into its frame.
To ensure the deficient practice does not recur the education manager will provide inservice education to the maintenance staff regarding protecting hazardous areas, including doors must self-close and latch into its frame, be free from penetrations, and may not be obstructed from self-closing. Maintenance staff will conduct weekly rounds to ensure doors to hazardous areas are not being propped open. The maintenance staff will conduct quarterly door inspections to ensure they are free from penetrations, self-close, and latch into its frame. Findings will be reported to the Safety Committee quarterly by the Maintenance supervisor. This is an ongoing process.
The Maintenance supervisor is responsible for compliance.

K307 NFPA 101:PROTECTION - OTHER

REGULATION: Protection - Other List in the REMARKS section any LSC Section 18.3 and 19.3 Protection requirements that are not addressed by the provided K-tags, but are deficient. This information, along with the applicable Life Safety Code or NFPA standard citation, should be included on Form CMS-2567.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 17, 2017

Citation Details

Based on observation and interview during the Life Safety Code Survey completed on 6/9/17, the Clean Agent Fire Extinguishing System in the Information Services Room was not maintained. This affected one (First Floor) of three resident use floors. The findings are: 1. Observation on the First Floor on 6/6/17 at approximately 8:45 AM revealed the Information Services Room was equipped with a Clean Agent Fire Extinguishing System. Further observation revealed a sign on the wall read HFC 227ea Extinguishment System and no inspection tag was located on the system's control panel or on the tank. Interview with the Maintenance Supervisor at the time of the observation revealed he did not know which outside contractor installed the system or which outside contractor inspects the system. A second interview with the Maintenance Supervisor on 6/8/17 at approximately 1:35 PM revealed he believes the extinguishment system in the Information Services Room was installed approximately three years ago and has not been inspected since then. The Maintenance Supervisor added that he had no owner's information from the manufacturer of the system, no information on the installation of the system, and no inspection reports for the system. According to the National Fire Protection Association (NFPA) 2001: Standard on Clean Agent Fire Extinguishing Systems, 2012 edition, at least annually, all systems shall be thoroughly inspected and tested for proper operation by personnel qualified in the installation and testing of clean agent extinguishing systems and the inspection report with recommendations shall be filed with the owner of the system. This document also states at least semiannually, the agent quantity and pressure of refillable containers shall be checked 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5.5, 2.2 2012 NFPA 2001: 7.1, 7.1.1, 7.1.2, 7.1.3

Plan of Correction: ApprovedJuly 19, 2017

The facility recognizes that all residents have the potential to be affected by this deficient practice. To protect all potentially affected residents and be in compliance, the facility will ensure the Clean Agent Fire Extinguishing System located in the Information Services Room is inspected/tested annually and semi-annually the agent quantity and pressure of refillable containers are checked by Great Lakes. This inspection is scheduled to be done on 7/14/17 by Great Lakes.The Maintenance supervisor will complete any recommendations made and maintain the inspection reports on file. Inspection results and follow up recommendations will be reviewed at the QA Committee meeting.
This process is ongoing.
The Maintenance supervisor is responsible for compliance.

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: June 30, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/9/17, the Generator Room was not protected by a supervised automatic sprinkler system and did not meet the conditions for the room to be exempt from being sprinklered. This affected one of one Basement. The finding is: 1. Observation in the Basement on 6/5/17 at approximately 2:05 PM revealed the Generator Room was not protected by an approved supervised automatic sprinkler system. Further observation at this time revealed the room contained combustible items in storage, including, but not limited to: - Various breathing equipment for bio-terrorism response - One folded cot - One cabinet that measured approximately three feet wide by 18 inches deep by six feet high that contained various maintenance supplies - One nuts and bolts bin that measured approximately two and a half feet wide by one foot deep by four feet high - One full plumbing cart that measured approximately two feet wide by 18 inches deep by three and a half feet high - Two metal lockers that contained various maintenance supplies - One ice machine that measured approximately one foot wide by 18 inches deep by one foot high - One grease gun - One Bernz-o-matic torch - One lockout kit - One unused first aid kit - Multiple paint trays - Two metal bed assist bars - Multiple temporary lighting fixtures Interview with the Maintenance Supervisor at the time of the observation revealed the storage cabinets were always kept in this room, but the breathing equipment for bio-terrorism response was usually stored in the Penthouse, but had been temporarily stored in the Generator Room due to an ongoing construction project in the Penthouse. Further interview with the Maintenance Supervisor revealed the Generator Room had no sprinkler coverage. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.5, 19.3.5.1, 9.7, 9.7.1, 9.7.1.1 2010 NFPA 13: 8.15, 8.15.10.3

Plan of Correction: ApprovedJuly 19, 2017

K351- All residents have the potential to be effected by this deficient practice.
For fire safety/prevention and in accordance with NFPA, on 6/28/2017, all combustible items located in the generator room were removed including , but, not limited to:
various breathing equipment for bio -terrorism response, one folded cot, one cabinet that measured approximately three feet wide by 18 inches deep by six feet high that contained various maintenance supplies, one nuts and bolts bin that measured approximately two and a half feet wide by one foot deep by four feet high, one full plumbing cart that measured approximately two feet wide by 18 inches deep by three and a half feet high, two metal lockers that contained various maintenance supplies, one ice machine that measured approximately one foot wide by 18 inches deep by one foot high, one grease gun, one bernz-o-matic torch, one lock out tagout kit, one unused first aid kit, multiple trays, two metal bed assist bars, multiple lighting fixtures.
All maintenance staff were re-educated regarding appropriate storage locations and not storing items in the generator room including not storing combustible items. To ensure the deficient practice does not recur the maintenance supervisor and the NHA will monitor the generator room monthly to ensure it remains free of combustibles. Monitoring results will be reviewed a QA Committee meeting monthly.
Responsible Party: Director of Maintenance

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 more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/9/17, it was determined that a stairway means of egress was not maintained. Issues included a storage room that was built in a stairway. This affected two (First, Second Floors) of three resident use floors and one of one Basement. The finding is: 1. Observation in the Main Entrance stairway on 6/5/17 at approximately 1:44 PM revealed a room was built in the stairway at the Basement level and contained storage boxes. Further observation revealed the room measured approximately eight feet long by four feet wide and the only entrance to this room was located within the stairway. Additional observation at this time revealed this stairway served the Basement through Second Floors of the facility. Interview with the Maintenance Supervisor at the time of the observation revealed the room in the stairway was not new. Interview with the Acting Administrator on 6/8/17 at approximately 2:10 PM revealed she was not aware that a room was built into this stairway and the boxes contained in this room are medical records awaiting destruction. According to the National Fire Protection Association (NFPA) 101: Life Safety Code, 2012 edition, enclosed, usable spaces within exit enclosures shall be prohibited, including under stairs, unless the space has the same fire resistance as the exit enclosure and the entrance to the space is not located within the stair enclosure. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 101: 19.2.2.3, 7.2.2, 7.2.2.5.3, 7.2.2.5.3.1, 7.2.2.5.3.2

Plan of Correction: ApprovedJune 28, 2017

The facility will ensure stairways and smoke proof enclosures used as exits are maintained as a means of egress.
All residents have the potential to be affected by this deficient practice.
To comply with NFPA 101 Life Safety code and to protect the residents, the storage room built in the Main Entrance stairway at basement level will be removed.
The Maintenance supervisor and the Nursing Home Administrator will conduct weekly environmental rounds to ensure all stairways used as exits are maintained as a means of egress. this process will be ongoing.
Results of the rounds will be reported to the Safety Committee monthly by the Maintenance supervisor.
The Nursing Home Administrator is responsible for compliance.

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: Pattern
Severity: Potential to cause more than minimal harm
Citation date: June 9, 2017
Corrected date: August 4, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 6/9/17, smoke barrier walls were not complete from floor to ceiling/ roof deck, were not designed to have at least a 30-minute fire resistance rating, and were not designed to resist the passage of smoke. This affected three (First, Second, Third Floors) of three resident use floors. The findings are: 1. Observation above the ceiling tiles on the Third Floor, above the smoke barrier doors outside of Resident Room #308, on 6/8/17 at approximately 9:05 AM, revealed an area of drywall approximately five inches high by four inches wide was missing around a vent. Further observation revealed in this area, the smoke barrier wall was constructed of only one layer of drywall. Interview with the Maintenance Supervisor at the time of the observation revealed there have been no new projects in this area and the missing drywall must have been overlooked for the last ten years. 2. Observation above the ceiling tiles on the Second Floor, above the smoke barrier doors outside of Resident Room #237, on 6/8/17 at approximately 9:36 AM revealed a one inch diameter penetration was located around a one-half inch diameter BX cable. Further observation revealed the penetration was present on both sides of the smoke barrier wall. Interview with the Maintenance Supervisor at the time of the observation revealed the penetration may be the result of new outlets installed by an outside electrician last November. 3. Observation above the ceiling tiles on the Second Floor on 6/8/17 at approximately 9:45 AM revealed a one square inch penetration through the wall in the Director of Nursing's office. Interview with the Maintenance Supervisor at the time of the observation revealed he was not sure if this wall is located along a smoke barrier. 4. Observation above the ceiling tiles on the First Floor. above the single leaf cross corridor smoke barrier door that leads to the Urgent Care Center, on 6/8/17 at approximately 9:55 AM revealed a two and a quarter inch diameter penetration was located around a two-inch diameter sprinkler pipe. Additional observation in this location revealed a one square inch penetration was located around a one and a half inch diameter white plastic accordion tube. Additional observation in this location revealed a one-half inch diameter open unsealed penetration. Interview with the Maintenance Supervisor at the time of the observations revealed this wall was part of the smoke barrier. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.7.3, 8.5, 8.5.1, 8.5.2, 8.5.2.1, 8.5.2.2

Plan of Correction: ApprovedJune 30, 2017

This plan demonstrates the facility's desire to comply with the regulations.
K 372- Subdivision of Building Spaces- Smoke barrier construction Directed Plan of Correction:
Assessment of causative factors that may have contributed to the issues identified in the deficiency:
*New data lines placed
*Outside vendors (eg: placed sprinkler system, duct work, electrical work, etc.)
*Lack of communication with vendors and lack of supervision post-project completion.
*Fire rated caulking is the material that degrades, dries out, and falls out over time requiring replacement.
The interventions undertaken to eliminate and correct the causative factors identified:
*IT department will notify maintenance of any planned installations, including documentation of location, date, and time or install.
*Outside vendors will have a discussion at the beginning of a project and a follow-up inspection at the end of the project with the maintenance supervisor to ensure any penetrations have been repaired.
* Revise policy to reflect outside vendors must meet with maintenance supervisor to discuss expectations and have an inspection at the end of the project to ensure any penetrations have been repaired. Educate all maintenance staff on policy revision.
*Fire rated caulking materials and penetration repair will be inspected on a set scheduled preventative maintenance plan with a log maintained stating date/time of inspection and any action taken. Educate maintenance staff about the need for routine inspection and repair of any penetrations in smoke barrier walls. Monthly report will be given by the maintenance supervisor to the Safety Committee.
*Maintenance supervisor to conduct 100% audit on smoke barrier walls for any penetrations and report findings at 7/25/17 Safety Committee meeting.
*Maintenance supervisor to develop a scheduled inspection and preventative maintenance program of smoke barrier walls (No penetrations). (Example: inspect one floor per week, so all floors are done once per month).
*This will be an ongoing Preventative Maintenance Program with findings reported monthly to the Safety Committee by the maintenance supervisor.
The triggers identified that will signal all staff of an evolving problem or deficient practice situation:
*New data lines added
*Outside vendor projects.
*Results of routine inspections.
The facility will measure whether the efforts are successful or unsuccessful in maintaining compliance by:
* Zero penetrations in smoke barrier walls.
All residents are potentially affected by this deficient practice. As immediate corrective action the QA Committee convened on 6/27/17. A directed plan of correction was conducted by J. Kratts, RN, BSN to develop a plan of action to correct a repeat deficient practice of not maintaining penetration-free smoke barrier walls. Also, drywall on Third floor was replaced outside room #308; on second floor the penetrations were repaired outside room #237 and the DON's office wall; and on First floor the penetrations were repaired in the single leaf cross corridor smoke barrier door leading to UCC.
To ensure the deficient practice does not recur, the maintenance supervisor will conduct a 100% audit on smoke barrier walls for any penetrations and report findings at the 7/25/17 Safety Committee meeting. Policy will be revised to reflect outside vendors must meet with the maintenance supervisor at the beginning of a project to discuss expectations and have an inspection at project completion to ensure any penetrations have been repaired. Maintenance supervisor will develop a scheduled preventive maintenance program to monitor smoke barrier walls for penetrations and repair any found. The results of these inspections will be reported monthly at the Safety Committee meeting by the maintenance supervisor. The Nursing Home Administrator will educate maintenance staff about the need for routine inspections and repair of any penetrations in smoke barrier walls.
This will be an ongoing process.
Responsible Person: Nursing Home Administrator