Chautauqua Nursing and Rehabilitation Center
January 18, 2019 Certification/complaint Survey

Standard Health Citations

E3BP 402.6(a):CRIMINAL HISTORY RECORD CHECK PROCESS

REGULATION: Section 402.6 Criminal History Record Check Process. (a) The provider shall ensure the submission of a request for a criminal history record check for each prospective employee. If a permanent record does not exist for the prospective employee, the Department shall be authorized to request and receive criminal history information from the Division concerning the prospective employee in accordance with the provisions of section 845-b of the Executive Law. Access to and the use of such information shall be governed by the provisions of such section of the Executive Law. The Division is authorized to submit fingerprints to the FBI for a national criminal history record check.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

Based on interview and record review conducted during the Standard survey completed on 1/18/19, the facility did not have documentation that fingerprinting had been conducted on a provisional employee and fingerprint information for the provisional employee had been submitted to New York State Department of Health Criminal History Record Check (CHRC) for one (Housekeeper) of five employees that were hired in the last four months and reviewed for compliance with CHRC regulations. The finding is: Review of an undated facility policy entitled Criminal Background Checks (Fingerprinting) revealed the facility will obtain criminal background checks for all non-licensed applicants before hire. Both state and federal criminal history check will be performed. Pursuant to State Law, each provider must identify at least one (1) Authorized Person who will be responsible for submitting CHRC request to the Department of Health (DOH) and receiving the CHRC determination from the Department of Health while maintaining the confidentiality of the material as required by state law. The Human Resources Director is authorized to submit the CHRC request to the Department with the L1 employee number and to receive the DOH eligibility determination. In the absence of the Human Resources Director, CHRC checks are done by designated alternate. 1. Record review of Employee #5 (Housekeeper) personnel file on 1/16/19 revealed there was no documentation the employee had been finger printed and the fingerprint information for the employee had been submitted to New York State Department of Health Criminal History Record Check (CHRC). Further review of the employee file revealed Employee #5 had worked at the facility for six days between 10/3/18 and 10/10/18. During an interview on 1/16/19 at 11:39 AM, the Director of Human Resources (Authorized Person) stated, she had been out of the facility when the CHRC process for Employee #5 had started and somehow the paperwork for the employee had been miss placed. The Director of Human Resources further stated, the employee worked at the facility for six days between 10/3/18 and 10/10/18 and she submitted all employee information to CHRC. The Director of Human Resources also stated, on or about 10/10/18 she was going to terminate the employee from the facility and the CHRC system. She realized the employee had not been sent for fingerprinting and the employee's fingerprint information had never been submitted to New York State Department of Health Criminal History Record Check. During an interview on 1/16/19 at 12:41 PM, the Environmental Services Supervisor stated, Employee #5 worked on the Ground, First, and Second Floors on 10/3/18, 10/4/18,10/5/18,10/8/18, and 10/10/18 and on the Ground Floor on 10/7/18. Review of the (MONTH) (YEAR) Housekeeping schedule on 1/16/19 revealed, Employee #5 worked at the facility on 10/3/18,10/4/18,10/5/18,10/7/18, 10/8/18, and 10/10/2018. 402.4(a)(1) 402.6(a)(b) 402.9(a)(1)(iv)

Plan of Correction: ApprovedFebruary 5, 2019

I. Corrective action for employee found to have been affected by the deficient practice:
All employee files were immediately audited to ensure a New York State Department of Health Criminal History Record Check (CHRC) was completed on all employees and that documentation of fingerprinting had been conducted on any provisional employee.
Completion: 1/16/19
Responsibility: Director of Human Resources
II. Identification and corrective action for employees having the potential to be affected by the same deficient practice:
All human resource personnel were educated and in-serviced on Criminal Background Checks (fingerprinting) Policy & Procedure.
All human resource personnel will receive account access to the New York State Department of Health Criminal History Record Check (CHRC). In the event the Director of Human Resources is not present during the hiring process, a Human Resource designee will enter the employee into CHRC.
Completion: 03/19/2019
Responsibility: Director of Human Resources
III. The systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility has an audit tool that will review all new employee hires to ensure they reflect facility documentation of fingerprinting and submission to New York State Department of Health Criminal History Record Check (CHRC) is conducted.
An audit will be completed by Human Resources on all new employee hires quarterly for 12 months, then biannually thereafter.
Completion: 03/19/2019
Responsibility: Director of Human Resources
IV: Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
All audits will be reported during each QAPI meeting to determine the effectiveness of the process.
Completion: 03/19/2019
Responsibility: Director of Human Resources

FF11 483.15(c)(3)-(6)(8):NOTICE REQUIREMENTS BEFORE TRANSFER/DISCHARGE

REGULATION: §483.15(c)(3) Notice before transfer. Before a facility transfers or discharges a resident, the facility must- (i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman. (ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and (iii) Include in the notice the items described in paragraph (c)(5) of this section. §483.15(c)(4) Timing of the notice. (i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged. (ii) Notice must be made as soon as practicable before transfer or discharge when- (A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section; (B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section; (C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section; (D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or (E) A resident has not resided in the facility for 30 days. §483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following: (i) The reason for transfer or discharge; (ii) The effective date of transfer or discharge; (iii) The location to which the resident is transferred or discharged; (iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request; (v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman; (vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and (vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act. §483.15(c)(6) Changes to the notice. If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available. §483.15(c)(8) Notice in advance of facility closure In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at § 483.70(l).

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey completed on 1/18/19, the facility did not ensure that written notification was sent to the resident, the resident's representative, and a representative from the Office of the State-Long Term Care (LTC) Ombudsman of the resident's transfer or discharge for two (Residents #145, 199) of two residents reviewed for admission, transfer, discharge notice requirements. Specifically, there was no documented evidence the resident, resident's representative, or ombudsman were notified in writing by the facility when the residents were transferred to a hospital from the facility. The findings are: The facility policy entitled Discharge Notice dated 1/1/15 documented when a resident is temporarily transferred on an emergency basis to an acute care facility, notice of the transfer may be provided to the resident and resident representative as soon as practicable. Copies of the notices for emergency transfers must also still be sent to the ombudsman, but they may be sent when practicable, such as in a list of residents on a monthly basis. 1. Resident #199 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) accepted into the database included Discharge Assessment Return Anticipated dated 12/11/18 and 12/20/18. Review of the nursing Progress Notes dated 12/11/18 revealed the resident was sent to the hospital and admitted for UTI (urinary tract infection) [MEDICAL CONDITION] (a severe blood infection). Additionally, a Progress Note dated 12/20/18 revealed the resident was sent to the hospital and admitted for UTI and leukocytosis (elevated white blood cell count). Review of the entire medical record revealed there was no documented evidence that discharge notices were provided to the resident, resident's representative, and a copy was sent to the Office of the State Long-Term Care Ombudsman as required. During an interview on 1/18/19 at 11:00 AM, the Discharge Planner stated she has not been giving the discharge notice to the residents who go to the hospital nor has she been letting the ombudsman's office know about it. The discharge planner stated it was just brought up recently that she should be doing it. During an interview on 1/18/19 at 12:15 PM, the Social Worker (SW) stated the Discharge Planner was supposed to have been giving the notices. A previous staff member was responsible for doing it but she no longer works at the facility. During a telephone interview on 1/18/19 at 12:40 PM, the ombudsman representative stated they have not been getting the notices of transfers or discharges from this facility. 2. Resident #145 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 12/8/18 documented the resident had long and short-term memory problems, rarely understood by others, and rarely understands others. Review of the Minimum Data Set (MDS - a resident assessment tool) accepted into the database included Discharge Assessment Return Anticipated dated 10/28/18 and 11/1/18. Review of the entire medical record revealed there was no documented evidence that discharge notices were provided to the resident, resident's representative, and a copy was sent to the Office of the State Long-Term Care Ombudsman as required. Review of the nursing Progress Notes dated 10/28/18 at 12:55 AM revealed that the resident's J tube (a tube that is inserted into the small intestine for venting air or drainage or providing an alternate way for feeding) was leaking and the facility staff could not obtain an X-ray to determine the location of the tube. The resident left the facility at 1:25 AM and went to the emergency department at a local hospital. The hospital then transferred the resident to another hospital that was more familiar with her case. The resident returned to the facility on [DATE] at approximately 4:00 PM. A review of the Social Work Progress note dated 10/31/18 revealed that the resident was evaluated for an admission/ readmission by Social Work. A review of the nursing Progress Notes dated 11/1/18 revealed that the resident was to be sent to a medical center for scheduled surgery. The resident was discharged from the facility on 11/1/18 and was readmitted to the facility on [DATE]. A review of a Social Work Progress note dated 11/8/18 revealed that the resident was evaluated for an admission/ readmission by Social Work. During an interview on 1/18/19 at 12:13 PM, Social Worker (SW) #2 revealed that she oversaw the unit that the resident was on. She did not send out a discharge letter to the facility's Ombudsman or the Ombudsman's office. She also stated that the person who used to do the discharge letters no longer works at the facility. She stated they used to send a fax to the Ombudsman office at the end of the month for all that month's discharges. She stated that they have not sent out discharge letters since that person left. 415.3(h)(1)(iv)(d)

Plan of Correction: ApprovedFebruary 5, 2019

I. Corrective action for resident found to have been affected by the deficient practice:

The Discharge Planner was educated and in-serviced immediately on policy & procedure titled Discharge Notice on 1/18/19.
Completion: 01/18/2019
Responsibility: Administrator
II. Identification and corrective action for residents having the potential to be affected by the same deficient practice:
The Social Work department will be educated and in-serviced on the policy & procedure titled Discharge Notice.
Completion: 03/19/2019
Responsibility: Administrator
III. The systemic changes to ensure that deficient practice does not recur:
To ensure the deficient practice not recur, the facility has created an audit tool that will track the transfers and discharges to ensure proper notification is provided to the resident, resident representative, and ombudsman in writing by the facility when the residents were transferred to a hospital from the facility. Each social worker will be responsible of their assigned unit to send the discharge notice to the resident, resident representative, and ombudsman.
A random audit completed by the Social Work department on 25 residents (5 residents from each of 5 units) on residents that have been discharged /transferred from the facility on a quarterly basis for 12 months, then biannually thereafter.
Completion: 3/19/2019
Responsibility: Administrator
IV: Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
The identified discharge notice issues will be incorporated into the QAPI program to ensure that the deficient practices do not recur. Results of these audits will be reported quarterly to review the effectiveness of its audit.
Completion 03/19/2019
Responsibility: Administrator

FF11 483.25(i):RESPIRATORY/TRACHEOSTOMY CARE AND SUCTIONING

REGULATION: § 483.25(i) Respiratory care, including tracheostomy care and tracheal suctioning. The facility must ensure that a resident who needs respiratory care, including tracheostomy care and tracheal suctioning, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan, the residents' goals and preferences, and 483.65 of this subpart.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview, and record review completed during a Standard survey completed on 1/18/19, the facility must ensure that a resident who needs respiratory care, is provided such care, consistent with professional standards of practice, the comprehensive person-centered care plan for two (Resident #15 and #181) of two residents reviewed for respiratory care. Specifically, both resident's oxygen (O2) concentrators had filters that were soiled with thick grey dusty debris and unlabeled, undated O2 tubing. The findings are: Review of the policy and procedure entitled Oxygen Equipment dated 1/1/15 revealed all oxygen equipment will be maintained on a monthly basis. A supply of replacement filters, tubing and batteries are kept in stock for the various brands of O2 concentrators. Filters are cleaned weekly and the tubing is changed every two weeks. 1. Resident #15 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The Minimum Data Set (MDS - a resident assessment tool) dated 1/4/19 revealed the resident was sometimes understood, sometimes understands and was severely cognitively impaired. The MDS documented the resident required the use of oxygen therapy. The comprehensive care plan (CCP) last reviewed 10/17/18 documented the resident had impaired [MEDICAL CONDITION] function related to [MEDICAL CONDITION] with interventions that included oxygen per the physician's orders [REDACTED]. The undated Order Review Report documented an order to apply O2 via nasal cannula (NC) at two liters at bedtime (HS) when resident refuses [MEDICAL CONDITION] (Continuous Positive Airway Pressure, treatment that uses mild air pressure to keep your breathing airways open) machine and remove in the morning. Review of the Medication and Treatment Administration Records (MAR and TAR) dated (MONTH) (YEAR) and (MONTH) 2019 revealed an order entry to apply O2 via nasal cannula at two liters at HS when resident refuses [MEDICAL CONDITION] machine and remove in the morning. Further review of the TAR with an order date of 1/16/19 revealed to change O2 filter and change tubing weekly on Tuesdays on the night shift. There was no documented evidence on the (MONTH) TAR to change the O2 concentrator filters or change the tubing. Intermittent observations of Resident #15 from 1/15/19 to 1/18/19 revealed the following: - 1/15/19 at 6:54 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled 1/14/19 and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/16/19 at 7:35 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/17/19 at 7:00 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was labeled and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/18/19 at 11:30 AM - Resident was out of bed and O2 was not in use. The filter on the left side of the oxygen concentrator was still covered with thick grey debris. 2. Resident #181 was admitted to the facility on [DATE] with a [DIAGNOSES REDACTED]. The MDS dated [DATE] documented the resident was understood, understands and was moderately cognitively impaired. The MDS also documented the resident required the use of oxygen therapy. The comprehensive care plan (CCP) last reviewed 12/25/18 documented the resident [MEDICAL CONDITION] of the left upper lung. The undated Order Review Report documented an order to apply O2 at two liters via nasal cannula continuously. Review of the MAR and TAR dated (MONTH) (YEAR) and (MONTH) 2019 revealed order entry for O2 via nasal cannula at two liters continuously. Further review of the TAR with an order date of 1/16/19 reveal change O2 filter and change tubing weekly on Tuesdays on the night shift. There was no documented evidence on the (MONTH) TAR to change the O2 concentrator filters or change the tubing. Intermittent observations of Resident #181 from 1/14/19 to 1/18/19 revealed the following: - 1/14/19 at 2:10 PM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was not dated or labeled, and the filter on the left side of oxygen concentrator was covered with thick grey debris. - 1/15/19 at 2:00 PM - Resident was in bed and the O2 tubing was labeled 1/15/18. The filter on left side of the oxygen concentrator was still covered with thick grey dusty debris - 1/16/19 at 2:08 PM - Resident was sitting up in a w/c (wheel chair) in their room and O2 was on at two liters via NC. The left side filter of the oxygen concentrator remained dusty with grey debris. - 1/17/19 at 9:59 AM - Resident was in bed and O2 was on at two liters via NC. The oxygen tubing was not labeled, and left side filter was covered with thick grey debris. - 1/18/19 at 11:34 AM - Resident was in bed and O2 was at two liters via. The oxygen tubing was not labeled, and the left side filter of the oxygen concentrator was still covered with thick grey debris. During an interview on 1/16/19 at 2:17 PM, the Licensed Practical Nurse (LPN #1) stated the 11:00 PM to 7:00 AM shift changes the O2 tubing weekly, extension tubing would be changed monthly, and filters get cleaned by the 11:00 PM to 7:00 AM shift as well. There would be an order and it would be on the MAR/ TAR; any resident on O2 would have orders on the MAR/ TAR to change the tubing and clean the concentrator filters. During an interview on 1/16/19 at 2:26 PM, the Registered Nurse Unit Manager (RN UM #2) stated the LPNs on the 11:00 PM to 7:00 AM shift maintain the oxygen equipment; they change the tubing and clean the filters weekly. There should be orders and it would on the MAR/ TAR. If it's not on the MAR/ TAR they wouldn't know to change the tubing or clean the filters. During an interview on 1/17/19 at 7:12 AM, RN UM #2 stated she checked all the residents on the unit for orders to change the oxygen tubing and to clean the filters weekly. Only one out of the seven or eight residents had an order. She wasn't sure if it didn't get carried over when they switched to electronic medical records. 415.12(k)(6)

Plan of Correction: ApprovedFebruary 5, 2019

I. Corrective action for resident found to have been affected by the deficient practice:
All oxygen concentrators filters were cleaned and all oxygen tubing were immediately replaced, labeled and dated.
Completion: 1/18/19
Responsibility: Director of Nursing
II. Identification and corrective action for residents having the potential to be affected by the same deficient practice:
All Licensed Nurses will be in-serviced on the Oxygen Equipment Policy & Procedure.
Completion: 03/19/2019
Responsibility: Director of Nursing
III. The systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility has an audit tool to ensure the MAR and TAR reflect appropriate orders for changing and cleaning oxygen filter and labeling and dating oxygen tubing.
A random audit will be completed by Nursing on 15 residents quarterly for 12 months, then biannually thereafter.
Completion: 03/19/2019
Responsibility: Director of Nursing
IV: Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
All audits will be reported during each QAPI meeting to determine the effectiveness of the process of maintaining oxygen equipment.
Completion: 03/19/2019
Responsibility: Director of Nursing

Standard Life Safety Code Citations

K307 NFPA 101:ELECTRICAL EQUIPMENT - POWER CORDS AND EXTENS

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

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 1/18/19, extension cords were not properly maintained. In-use extension cords were being used to supply a permanent source of power to electrical equipment. This affected two (Ground, Second Floors) of three resident use floors. The findings are: 1a. Observation of the Ground Floor on 1/14/19 at 2:52 PM revealed an extension cord was being used to supply power to a reach-in cooler in the Kitchen. b. Observation of the Ground Floor on 1/14/19 at 3:16 PM revealed an extension cord was being used to supply power to components of the building's phone system in Communications room [ROOM NUMBER]. During an interview at the time of the observation, the Director of Plant Operations stated the extension cord had been in the room for a long time. c. Observation of the Ground Floor on 1/14/19 at 3:45 PM revealed an extension cord was being used to supply power to a printer in the Dietary Clerk's office, room [ROOM NUMBER]. During the observation, the Director of Plant Operations stated he was not aware that the extension cord was being used in the office. d. Observation of the Second Floor on 1/14/19 at 3:45 PM revealed an extension cord was being used to supply power to a bed in resident room [ROOM NUMBER] on the 2A Unit. During the observation, the Director of Plant Operations stated the facility had conducted a bed audit of resident rooms in (MONTH) (YEAR) and the extension cord was not in the room. During an interview on 1/18/19 at 11:34 AM, the Plant Operations Director stated the facility conducted quarterly bed audits and the facility did not have logs for the audits. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 10.2.4, 10.2.4.2, 10.2.4.2.3, 10.2.3, 10.2.3.3.3 2011 NFPA 70: 110.3(A)(1), 400.8(1), 590.3(B)

Plan of Correction: ApprovedFebruary 8, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Corrective action for resident found to have been affected by the deficient practice:
1a. Extension cord used to supply power to a reach-in cooler in the Kitchen was immediately removed and permanently re-wired with a junction box.
1b. The extension cord being used to supply power to the phone system in the Communication Room was immediately removed and replaced with an approved 1363 power strip.
1c. The extension cord used to supply power to a printer in the Dietary Clerk's office was immediately removed. The printer was re-located in the room to an area that can be plugged in directly to the wall.
1d. The extension cord found to supply power to a bed in resident room [ROOM NUMBER] was immediately removed and the the bed was plugged in directly to a wall outlet.
Completion: 01/14/2019
Responsibility: Director of Plant Operation
II: Identification and corrective action for residents having the potential to be affected by the same deficient practice:
A full-house audit was conducted for the facility (including all resident rooms) to ensure no extension cords were being used to supply power.
An in-service for all staff will be completed on extension cords and the inappropriate use as a substitute for fixed wiring of a fixture and the appropriate notification and removal if an extension cord is found.
Completion: 03/19/2019
Responsibility: Director of Plant Operation
III. Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility has an audit tool that be conducted facility wide quarterly for 12 months, then bi-annually thereafter checking all rooms and ancillary areas to ensure there is no use of extension cords in the building.
Completion: 03/19/2019
Responsibility: Director of Plant Operation
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
All audits will be reported during each QAPI meeting to determine the effectiveness of the audit and to ensure the deficient practice does not recur.
Completion: 03/19/2019
Responsibility: Director of Plant Operation

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: April 5, 2019
Corrected date: April 15, 2019

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 1/18/19, the building's emergency generator was not properly maintained. The emergency generator's remote annunciator was not located in an area that was readily observed by operating personnel at regular work stations. This affected one of one emergency generator. The finding is: Per the 2012 edition of the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, 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 1. Observation of the Ground Floor on 1/14/19 at 3:38 PM revealed the emergency generator's remote annunciator was installed in an alcove of the service corridor between Clean Supply room [ROOM NUMBER] and Maintenance Tool room [ROOM NUMBER]. During an interview at the time of the observation, the Plant Operations Director stated this was the remote annunciator for the emergency generator and there were no other generator annunciators in the building. During an interview on 1/17/16 at 3:56 PM, the Plant Operations Director stated the facility had one maintenance worker on second shift, 3:00 PM to 11:00 PM, and the worker answers maintenance calls and delivers a second round of oxygen cylinders to the units. The Plant Operations Director further stated that the facility had one maintenance worker on the third shift, 11:00 PM to 7:00 AM, and the worker answers maintenance calls, takes the garbage out, and strips and waxes floors. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4, 6.4.1.1.17Based on record review and interview conducted during an Offsite Post-Survey Revisit completed on 4/5/19, the emergency generator's remote annunciator was not located in an area that was readily observed by operating personnel at regular work stations. This is a continuing deficiency from the Life Safety Code Survey completed 1/18/19 and affected one of one emergency generator. The finding is: Per the 2012 edition of the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, 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. 1. Review of the facility's accepted Plan of Correction (P(NAME)), for the Standard/Life Safety Code survey completed 1/18/19, revealed that a facility hired contractor would connect the emergency generator's remote annunciator to a readily observed personnel work station at the Ground Unit Nursing Station by 3/19/19. Review of documentation provided by the facility as part of the offsite Post-Survey Revisit revealed the contractor provided a quote dated 3/6/19 to provide and install monitor IAM for generator, program into existing system to monitor emergency generator running status. Review of an attestation, signed by the Director of Plant Operations, dated 3/19/2019 revealed that during a quarterly inspection, it was determined that the contractor was .unable to perform the work originally requested as they identified a problem due to the inability to program the panels due to their age. This attestation further stated work could be completed within three to four weeks dependent on the arrival of necessary parts. During a telephone interview on 4/5/19 at 10:50AM, the Administrator stated the repair would cost more than originally quoted and a part was needed so the installation of the remote annunciator would not negatively affect the fire panel. Further interview revealed the contractor ordered the part and it was scheduled to be shipped on 4/4/19. The contractor scheduled the installation to begin on 4/10/19 and be completed by 4/19/19. 10 NYCRR 415.29(a)(2),711.2(a)(1) 2012 NFPA 99: 6.4, 6.4.1.1.17

Plan of Correction: ApprovedApril 8, 2019

I. Corrective action for resident found to have been affected by the deficient practice:
The Director of Plant Operation immediately contacted (NAME)ston Controls to verify that the emergency generator's remote annunciator can be connected and readily observed by operating personnel at regular work station (Ground Unit Nursing Station).
Completion: 1/18/2019
Responsibility: Director of Plant Operation
II: Identification and corrective action for residents having the potential to be affected by the same deficient practice:
(NAME)ston Controls will complete facility work order to connect the emergency generator's remote annunciator to a readily observed personnel work station (Ground Unit Nursing Station).
Completion: 03/19/2019
Responsibility: Director of Plant Operation
III. Systemic changes to ensure that the deficient practice does not recur:
All staff will be re-inserviced on the annunciator located at the Ground Unit Nursing Station to be able to identify when the facility is on generator power.
Quarterly inspections will be completed by a qualified company to ensure a functioning connection between the emergency generator and the annunciator located at a regular work station (Ground Unit Nursing Station).

Completion: 03/19/2019
Responsibility: Director of Plant Operation
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
Director of Plant Operation will report to the QAPI meeting after each quarterly inspection to report compliance or to discuss any identified issues.

Completion: 03/19/2019
Responsibility: Director of Plant Operation

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

REGULATION: Gas Equipment - Cylinder and Container Storage Greater than or equal to 3,000 cubic feet Storage locations are designed, constructed, and ventilated in accordance with 5.1.3.3.2 and 5.1.3.3.3. >300 but <3,000 cubic feet Storage locations are outdoors in an enclosure or within an enclosed interior space of non- or limited- combustible construction, with door (or gates outdoors) that can be secured. Oxidizing gases are not stored with flammables, and are separated from combustibles by 20 feet (5 feet if sprinklered) or enclosed in a cabinet of noncombustible construction having a minimum 1/2 hr. fire protection rating. Less than or equal to 300 cubic feet In a single smoke compartment, individual cylinders available for immediate use in patient care areas with an aggregate volume of less than or equal to 300 cubic feet are not required to be stored in an enclosure. Cylinders must be handled with precautions as specified in 11.6.2. A precautionary sign readable from 5 feet is on each door or gate of a cylinder storage room, where the sign includes the wording as a minimum "CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING." Storage is planned so cylinders are used in order of which they are received from the supplier. Empty cylinders are segregated from full cylinders. When facility employs cylinders with integral pressure gauge, a threshold pressure considered empty is established. Empty cylinders are marked to avoid confusion. Cylinders stored in the open are protected from weather. 11.3.1, 11.3.2, 11.3.3, 11.3.4, 11.6.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 1/18/19, oxygen cylinders were not properly maintained. Issues included oxygen cylinders that were not properly secured. This affected one (Ground Floor) of three resident use floors. The finding is: 1a. Observation of the Ground Floor on 1/14/19 at 2:28 PM revealed one D size oxygen cylinder in a nylon carrying case was stored unsecured, lying on top of the crash cart in the Ground Floor Unit Oxygen Storage room. Further observation at this time revealed the cylinder was lying on the cover of the crash cart (emergency supply cart) at an approximate 45 degree angle. Continued observation revealed the room contained six E size oxygen cylinders in a rack. During the observation, the Plant Operations Director stated the oxygen cylinder was not on the cart when he conducted his building rounds at 6:30 AM and staff knew that oxygen cylinders had to be properly secured in a cart or rack. The Plant Operations Director further stated that the oxygen cylinder did not belong to the facility. During an interview on 1/14/18 at 2:29 PM, the Register Nurse (RN) Nurse Manager stated she was not sure how long the oxygen cylinder had been in the Oxygen Storage room and she was not sure who it belonged to. During an interview on 1/18/19 at 11:35 AM, the Plant Operations Director stated the facility conducts daily checks of the Oxygen Storage rooms during building rounds and the facility had no documentation for the checks. b. Observation of the Ground Floor on 1/14/19 at 3:22 PM revealed three H/K size oxygen cylinders in the Main Oxygen Storage room were secured with a single loose chain. Further observation at this time revealed there were hooks in the wall behind the cylinders. The room contained 12 H/K size oxygen cylinders, 54 E size oxygen cylinders and 12 D size oxygen cylinders. During an interview at the time of the observation, the Director of Plant Operations stated there were hooks in the wall behind the cylinders so they could be individually chained and someone must not have individually secured the cylinders. During an interview on 1/18/19 at 11:38 AM, the Plant Operations Director stated the delivery person for the company that supplied the facility with oxygen cylinders had not individually chained the oxygen cylinders in the Ground Floor Main Oxygen Storage room. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 11.3.3.1, 11.3.3.2, 11.3.2.6, 11.6.2.3(1)(11)

Plan of Correction: ApprovedFebruary 8, 2019

I. Corrective action for resident found to have been affected by the deficient practice:
1a. D size oxygen cylinder in nylon carrying case was removed from the emergency supply cart and placed in the appropriate secured holder in the O2 room.
1b. Each of three H/K size oxygen cylinders were secured individually by chains in the oxygen storage room.

Completion: 1/18/2019
Responsibility: Director of Nursing
II: Identification and corrective action for residents having the potential to be affected by the same deficient practice:
A full-house audit was completed of all oxygen storage rooms to ensure proper placement, storage and individual chains were used to secure the oxygen cylinders.
All Nursing, Therapy, Activity and Environmental Service employees will be in-serviced on proper storage, maintaining and securing of oxygen cylinders.
Completion: 03/19/2019
Responsibility: Director of Nursing
III. Systemic changes to ensure that the deficient practice does not recur:
To ensure the deficient practice does not recur, the facility has an audit tool that will do a full-house audit of all rooms that house oxygen tanks to ensure all oxygen cylinders are stored appropriately and secured individually.
The audit will be completed weekly for six (6) months, then bi-annually thereafter by Environmental Services for all oxygen storage areas.
Completion: 03/19/2019
Responsibility: Director of Nursing
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
All audits will be reported quarterly during each QAPI meeting to ensure that the deficient practices does not recur as well as the effectiveness of the audit.
Completion: 03/19/2019
Responsibility:Director of Nursing

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 18, 2019
Corrected date: March 19, 2019

Citation Details

Based on observation, interview and record review during the Life Safety Code survey completed on 1/18/19, the building's fire pump was not properly maintained and tested . The fire pump was not run under emergency power conditions. This affected three (Ground, First, Second Floors) of three resident use floors and one of one Basement. The finding is: Per the 2011 edition of the National Fire Protection Association (NFPA) Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection; Chapter 8 Fire Pumps: For installations having an automatic transfer switch, the following test shall be performed to ensure that the overcurrent protective devices (i.e., fuses or circuit breakers) do not open: (1) Simulate a power failure condition while the pump is operating at peak load (2) Verify that the transfer switch transfers power to the alternate power source (3) Verify that the pump continues to perform at peak load (4) Remove the power failure condition and verify that, after a time delay, the pump is reconnected to the normal power source 1. Observation of the Ground Floor on 1/15/19 at 3:43 PM revealed the transfer switch for the building's emergency generator was installed in the switch gear room. Observation of the exterior of the building on 1/15/19 at 9:05 AM revealed the fire pump for the building's automatic sprinkler system was located in the pump house. Review of the Forms for Inspection, Testing, and Maintenance of Fire Pumps dated 6/14/17 and 6/20/18 revealed the following were marked Not Applicable (N/A) on the reports: - Power failure simulated during peak flow? - Connection made to alternate power source? - After termination of simulated power failure did motor reconnect to the normal power source? During an interview on 1/16/19 at 1:57 PM, the Plant Operations Director stated the facility had a transfer switch for the emergency generator, and the fire pump was connected to the emergency generator. The Plant Operations Director further stated that the outside contractor who inspected and tested the building's fire pump was not testing the fire pump under emergency power and the facility was not testing the building's fire pump under emergency power. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2011 NFPA 25: 8.3.3.4

Plan of Correction: ApprovedFebruary 8, 2019

I. Corrective action for resident found to have been affected by the deficient practice:
(NAME)ston Controls was contacted immediately (1/16/2019) regarding inspection, testing and maintenance of fire pump. The report from 6/14/2017 and 6/20/2018 was questioned following the N/A marks regarding power failure simulation. The contracted company does not feel it necessary due to pump functioning on diesel rather than electric.
On 1/22/2019, the Director of Plant Operation performed the fire pump test under emergency power during the weekly generator load test in accordance with the National Fire Protection Association (NFPA) Standard for Inspection, Testing, and Maintenance of Water-Based Fire Protection; Chapter 8 Fire Pumps.
Completion: 1/22/2019
Responsibility: Director of Plant Operation
II: Identification and corrective action for residents having the potential to be affected by the same deficient practice:
A second (off shift) fire pump test will be conducted during the generator load test by the Director of Plant Operation to ensure compliance and proper functioning of the fire pump during emergency power in accordance with the NFPA Standards.
Completion: 3/19/2019
Responsibility: Director of Plant Operation
III. Systemic changes to ensure that the deficient practice does not recur:
A Fire Pump Test form will be completed bi-annually (including off-shift) to document performance of the fire pump under emergency power and in accordance with:
(1) Simulate a power failure condition while the pump is operating at peak load
(2) Verify that the transfer switch transfers power to the alternate power source
(3) Verify that the pump continues to perform at peak load
(4) Remove the power failure condition and verify that, after a time delay, the pump is reconnected to the normal power source.
Completion: 03/19/2019
Responsibility: Director of Plant Operation
IV. Quality Assurance Performance Improvement Program to ensure deficient practice does not recur:
The identified fire pump test will be incorporated into the QAPI program to ensure that the deficient practice does not recur. Results of these audits will be reported bi-annually to review the effectiveness of its audit.
Completion: 03/19/2019
Responsibility: Director of Plant Operation