Putnam Nursing & Rehabilitation Center
September 9, 2016 Certification Survey

Standard Health Citations

FF09 483.35(i):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: The facility must - (1) Procure food from sources approved or considered satisfactory by Federal, State or local authorities; and (2) Store, prepare, distribute and serve food under sanitary conditions

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

Based on observation, interview and record review conducted during a recertification survey, the facility did not ensure that: (1.) snack/nourishment refrigerators on 2 of 2 units (Second and Third Floors) were maintained in clean condition and contained resident's food that was dated; (2.) 1 of 2 snack/nourishment refrigerator had the proper temperature (Second Floor); and (3.) proper procedures were followed for cooling potentially hazardous food items; The findings are: 1. The Second Floor pantry was observed on 9/9/16 at 9:30 AM and revealed that the freezer was heavily soiled with an icy brown substance across the top back above the vent. Inside the refrigerator, a plastic bowl with lid containing two large, thick, cream colored disks, possibly cheese and labeled with a resident name, was undated. Observation of the Third Floor pantry on 9/9/16 at 9:45 AM revealed that the refrigerator thermometer indicated 48 degrees F (40 degrees F or below is the acceptable temperature). No temperature logs were observed. Both the freezer and the refrigerator were heavily soiled. Multiple spills were observed, some appeared to be juices. A defrosted and refrozen ice cream cup was in the freezer. The refrigerator contained a commercially-packaged sandwich in a plastic bag was not dated or labeled. Following inspection of the above-mentioned refrigerators, a dietary worker was interviewed about the conditions as described above. The dietary worker stated that cleaning the refrigerators is a shared responsibility of dietary and housekeeping. The FSD stated on 9/9/16 following the interview of the dietary staff, that the dietary staff is responsible in cleaning refrigerators in pantries. The FSD was then asked if there was a temperature log for the pantry refrigerators and stated that he did not have them but would develop one. The policy and procedure for the pantry refrigerators states that refrigerators will be wiped out on a daily basis and all food will be checked for appropriate labeling and that during delivery of nourishments, refrigerator temperatures will be checked and logged in pantry checklist. This procedure was not implemented. 2. A follow-up inspection of the kitchen was conducted on 9/9/16 at about 10:45 AM and the cook was asked about the facility's procedure for rapid cooling of potentially hazardous foods, to include meat and poultry. The cook stated that she had prepared the turkey early that morning to be served the following day. The cook stated that the turkey was baked from 6:00 AM to 9:00 AM and was placed in the refrigerator about an hour ago. The cook stated that once food items (in general) are cooled to 120 degrees Fahrenheit (F) they are placed in the refrigerator. The next time, the temperature of the item would be monitored the following morning. At 1:45 PM the surveyor, accompanied by the Food service Director (FSD), proceeded to the kitchen to monitor the temperature of the turkey. Several large pieces, noted by the FSD, to be about 9 lbs., were placed in an uncovered shallow pan stored in the walk-in refrigerator. The temperature of one of the pieces was noted to be 90 degrees F. The FSD stated at that time that it could not be determined if the standard of achieving 70 degrees F within two hours, after reaching 70 degrees F, would be met. Further interview with the FSD revealed that the pieces should be cut into half to promote rapid cooling. Additionally, when asked about the temperature log, the FSD stated that the temperature logs for cooling foods was not being maintained. The facility's policy and procedure for rapid cooling was reviewed. The policy and procedure stated that hot food would be cooled to 70 degrees F or lower within two hours, and then cooled down to 41 degrees F or lower within an additional four hours; large food items to be cut into smaller pieces; temperatures to be taken during the cooling process to make sure that time and temperature standards are met; and the food item and temperatures should be recorded on the Cool-Down Log. This procedure was not followed as observed. Additionally, one of the facility's procedures for rapid cooling states that roasted meats must be cut into pieces less than 10 lbs. According to the web site by the NY.gov, solid foods such as roast meats, should be cut into portions of six pounds or less after cooking and prior to cooling. 415.14(h))

Plan of Correction: ApprovedSeptember 30, 2016

F371A
Freezer and Refrigerators that were identified were emptied, defrosted and thoroughly cleaned. Thermometers were installed to insure acceptable temperatures. Policy and Procedure for pantry refrigerators and freezers were revised to include a pantry restock checklist which includes a refrigerator and freezer temperature log. This checklist and temperature log will be completed by a dietary staff member.
The Policy will also indicate daily cleaning of spills and removing undated and unlabeled items.
Dietary staff have had updated policy and procedure reeducation. Pantry inspection will be added to the biweekly multidisciplinary environmental rounds. Visual reminders have been placed to encourage employees to notify dietary staff if refrigerator is in need of cleaning.
Any concerns will be brought to monthly Quality Assurance Meetings.

F371B
1. The turkey was immediately cut into smaller pieces and placed in freezer for rapid cooling.
2. Immediate onsite counseling of rapid cooling policy and procedure given to staff to prevent improper cooling of potentially hazardous foods. Remainder of dietary staff educated.
3. Signage posted to provide visual reminders to ensure proper food preparation procedures.
4. Cool down log will be kept to track the rapid cooling of all meats and roasts. An audit sheet will be created and completed to ensure cooling log and technique compliant with regulations. This audit will be completed by food service manager/designee weekly for first quarter and then if effective, monthly or quarterly basis. All findings will be reviewed at Monthly Safety Meetings.

FF09 483.15(h)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: The facility must provide housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

Based on interviews and observations of the facility's environment during a recertification survey, it was determined that the facility did not maintain an orderly and sanitary interior on 3 of 3 facility units (3 East, 2 West, and 2 East) in order to provide its residents a safe and comfortable environment. Specifically, walls, doors, and resident room sinks were in disrepair, and soiled and stained privacy curtains were found in several residents' rooms. The findings include, but are not limited to: Observation of the facility was conducted on 9/8/16 between 10:00 AM and 1:00 PM. The following was noted: Unit 2 West - there were scuffed lower walls, scraped doors/door frames and scraped radiator front panels in Rooms 201, 202, 203 and 204. Unit 2 East - scuffed lower walls, scraped doors/door frames and scraped radiator in Room 224. Unit 3 East - Room 321, the lower door panel was separating from the door, and plaster on wall adjacent to bathroom was exposed; - Room 325, the door frame corner molding was pulling from the door panel and the lower wall adjacent to the bathroom was gouged with the baseboard molding separating from the wall. The wall was scraped and the sink was pulling from the wall; - Room 327, the lower wall was scraped and the radiator front panel was loose and scraped; - Room 330, the door panel was chipped; the corner of panel was pulling from the door and the wall was scraped; - Room 328, the wall was scraped, the corner molding was pulling from wall and the front radiator panel was scraped; - Room 329, molding was missing on entry into room and a broken tile was noted on the floor; - Room 326, the lower door panel was pulling form the door and bent metal edges were protruding from the door; - Room 318, the wall was scraped and gouged; - Room 332, paneling was observed hanging off the lower part of door; - Room 333, the sink was observed separating from wall. Further observations included soiled and stained privacy curtains observed in the rooms of Residents #91, #90, and #24. The facility administrator was interviewed on 9/8/16 at approximately 2:00 PM and stated that she is aware of the above observations. The facility administrator stated that the facility did not currently have a maintenance director who was responsible in ensuring that necessary repairs were done in order to sustain an orderly environment. The facility administrator further stated that she is in the process of seeking a replacement maintenance director. 415.5(h)(2)

Plan of Correction: ApprovedOctober 5, 2016

F 253
1. All individual findings were assessed and repaired and/or replaced as needed
2. Administrator and department managers had performed environmental rounds on all units to identify any other issues that were not included in SOD. No other issues were found.All dept. employees will be educated of this revised policy and procedure. Housekeeping room cleaning policy and procedure has been revised to include visual cleanliness and condition of privacy curtains. A room cleaning audit was developed to assist with maintaining an orderly and sanitary interior. This audit will be completed by housekeeping director/designee. 2 rooms on each unit weekly. These findings will be reviewed at monthly QA meetings.
3./4. Department managers were reeducated on bi weekly multidisciplinary environmental rounds. The education will include the areas of concern that were identified in SOD as well as other concerns, so that this deficiency does not occur again. Multi-disciplinary environmental audit sheet to include more detailed concerns. Facility maintenance personnel and dept. managers were again educated on the environmental rounds process by the facility administrator.
5. Weekly Environmental rounds will be performed by administrator/designee to ensure that all systems put into place to prevent deficiencies are effective and other issues do not occur. These results will be reviewed at monthly QA and Safety meetings.The corrective action and results of the biweekly environmental rounds will be tracked by facility Administrator/designee. The results of the audit will be reviewed at Monthly QA and Monthly Safety Meetings.

FF09 483.20(m), 483.20(e):PASRR REQUIREMENTS FOR MI & MR

REGULATION: A facility must coordinate assessments with the pre-admission screening and resident review program under Medicaid in part 483, subpart C to the maximum extent practicable to avoid duplicative testing and effort. A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental illness as defined in paragraph (m)(2)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission; (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation. (ii) Mental retardation, as defined in paragraph (m)(2)(ii) of this section, unless the State mental retardation or developmental disability authority has determined prior to admission-- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation. For purposes of this section: (i) An individual is considered to have "mental illness" if the individual has a serious mental illness defined at §483.102(b)(1). (ii) An individual is considered to be "mentally retarded" if the individual is mentally retarded as defined in §483.102(b)(3) or is a person with a related condition as described in 42 CFR 1009.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during a recertification survey, the facility did not ensure that a pre-admission screen was completed for a newly admitted resident with a [DIAGNOSES REDACTED]. This was evident for 1 of 30 residents (Resident #73) reviewed Pre-Admission Screening and Resident Review (PASRR). The findings are: Resident #73 has a [DIAGNOSES REDACTED]. The PASRR conducted on 6/29/16 revealed that the resident had a serious mental illness. This condition triggered the need for the completion of the Level 1 screen to determine if the resident should have a Level 2 screen. The Level 2 screen determines the need for specialized services and the appropriateness of long-term care placement in a skilled nursing facility. The Level 1 screen was not fully completed and the need for Level 2 screening was not determined. As of 9/9/16 the resident continued to reside in the facility. The facility administrator was interviewed in the afternoon of 9/9/16 and stated that the Social Worker was the staff member responsible in reviewing the PASRR completion. The Social Worker was interviewed in the afternoon of 9/9/16 and stated that he was responsible for reviewing the screen and that the appropriate agency will be contacted for the Level 2 screen. 415.23 (i)

Plan of Correction: ApprovedOctober 5, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** F285
1. IPRO was contacted and was in on 9/28/2016 to complete the need for Level 2 screening.
2. PASSR completion will be added to the pre admission checklist. The Admission department will ensure that these are present and complete.
3.
All residents prior to admission with a [DIAGNOSES REDACTED].
4. A monthly audit will be done by social worker/designee for all new admissions for each month to ensure that the Level I screen is completed and need for level 2 screening determined. Any concerns will be brought to social worker and addressed immediately. All findings will be reviewed at Monthly Quality Assurance meetings.

FF09 483.75(o)(1):QAA COMMITTEE-MEMBERS/MEET QUARTERLY/PLANS

REGULATION: A facility must maintain a quality assessment and assurance committee consisting of the director of nursing services; a physician designated by the facility; and at least 3 other members of the facility's staff. The quality assessment and assurance committee meets at least quarterly to identify issues with respect to which quality assessment and assurance activities are necessary; and develops and implements appropriate plans of action to correct identified quality deficiencies. A State or the Secretary may not require disclosure of the records of such committee except insofar as such disclosure is related to the compliance of such committee with the requirements of this section. Good faith attempts by the committee to identify and correct quality deficiencies will not be used as a basis for sanctions.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

Based on observation and interview conducted during a recertification survey, the facility did not implement an effective and efficient corrective action plan to address concerns related to maintaining and sustaining an orderly and sanitary environment in order to promote the residents' safety and comfort. The findings include, but are not limited to: Observation conducted on 9/8/16 from 10:00 AM and 1:00 PM revealed several environmental concerns that were previously identified during a previous survey. Scuffed and scraped walls, door/door frames, and radiators were identified. There were missing moldings, poorly maintained residents' room sinks and missing and/or loose wall panels. Potential cuts and abrasions from protruding bent metal edges on door panels were also identified. Additionally, soiled and stained privacy curtains were noted in several residents' rooms. (See F253 - E). The facility administrator was interviewed on 9/8/16 at approximately 2:00 PM and stated that she was aware of the above observations. The facility Administrator stated that the facility did not currently have a maintenance director who was responsible in ensuring that necessary repairs were done in order to sustain an orderly and sanitary environment. The facility administrator stated that she is in the process of seeking a replacement maintenance director. 415.27 (a-c)

Plan of Correction: ApprovedSeptember 30, 2016

F520
1. New Maintenance director has been hired and will be on staff full time (MONTH) 17, (YEAR). The maintenance staff will perform a facility inspection concentrating on those concerns that were previously identified during post surveys.
2. A preventive maintenance program will be initiated by new director to ensure that this practice does not recur.
3. Quality assurance meetings will now be held monthly as opposed to quarterly to increase participation and awareness.
4. Bi weekly environmental round sheets will also be reviewed to discuss progress as well as needs. These sheets will continue to be brought to monthly quality Assurance meetings.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Not less than two exits, remote from each other, are provided for each floor or fire section of the building. Not less than one exit from each floor or fire section shall be a door leading outside, stair, smoke-proof enclosure, ramp, or exit passageway. Only one of these two exits may be a horizontal exit. Egress shall not return through the zone of fire origin. 18.2.4.1, 18.2.4.2, 19.2.4.1, 19.2.4.2

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

The following waiver is on file with this office. Repeat waivers are granted based on previous justifications by the facility and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan to correct the issue. K032, S/S=B The interior stairways at the East and West ends of the building discharge into the ground floor corridor. 2000 NFPA 101 - 7-7.1 10 NYCRR 711.2(a)(1) 483.70(a)

Plan of Correction: ApprovedSeptember 30, 2016

Continue Waivers

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Electrical wiring and equipment shall be in accordance with National Electrical Code. 9-1.2 (NFPA 99) 18.9.1, 19.9.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2000 NFPA 101 LSC Chapter 9.1 UTILITIES 9.1.2 Electric. Electrical wiring and equipment shall be in accordance with NFPA 70, National Electrical Code, unless existing installations, which shall be permitted to be continued in service, subject to approval by the authority having jurisdiction. 1999 NFPA 70 - National Electrical Code Article 305 - Temporary Wiring, Section 305-2. All Wiring Installations (a) Other Articles. Except as specifically modified in this article, all other requirements of this Code for permanent wiring shall apply to temporary wiring installations. (b) Approval. Temporary wiring methods shall be acceptable only if approved based on the conditions of use and any special requirements of the temporary installation. Article 400 - Flexible Cords and Cables 400-8. Uses Not Permitted Unless specifically permitted in Section 400-7, flexible cords and cables shall not be used for the following: 1. As a substitute for the fixed wiring of a structure 2. Where run through holes in walls, structural ceilings suspended ceilings, dropped ceilings, or floors 3. Where run through doorways, windows, or similar openings 4. Where attached to building surfaces 5. Where concealed behind building walls, structural ceilings, suspended ceilings, dropped ceilings, or floors 6. Where installed in raceways, except as otherwise permitted in this Code 1999 NFPA 99: 3-3.2.1.2(d)2- Minimum Number of Receptacles. The number of receptacles shall be determined by the intended use of the patient care area. There shall be sufficient receptacles located so as to avoid the need for extension cords or multiple outlet adapters Based on observations and interview, the facility did not ensure that electrical wiring and equipment was installed in accordance with the National Electrical Code (NFPA 70) and NFPA 99. This was evidenced by multiple adapters, extension cords and relocatable power taps that were serially connected or daisy chained in resident rooms, patient care areas and a stairwell, and approved relocatable power taps that were not utilized properly. The findings are: During the life safety tour conducted on 9/8/16 and 9/9/16 between the hours of 10:30 AM - 2:30 PM, the following issues were noted: - At 11:00 AM, a tour of resident room [ROOM NUMBER] was conducted. It was noted that the resident's bed and lamp were plugged into a multiple adapter and the multiple adapter was plugged into the electrical outlet. - At 11:10 AM, a tour of resident room [ROOM NUMBER] E 3 revealed the resident's radio and lamp were plugged into an extension cord that was daisy-chained to a relocatable power tap. The power tap was plugged into the outlet. An examination of the power tap revealed the UL rating 1363 A for use with medical equipment. In an interview at the time of the findings, the Maintenance staff member stated that a preventative maintenance schedule is not in place. - At 11:35 AM, a tour of the lab room located on 2 East revealed an extension cord daisy-chained to the relocatable power tap. The extension cord was plugged into the electrical outlet. A refrigerator and a fan were plugged into the relocatable power tap. An additional extension cord was plugged into the same electrical outlet. In an interview at the time of the findings, the Maintenance staff member stated that the manufacturer's specifications for the relocatable power tap were not available. - At approximately 11:48 AM, resident room [ROOM NUMBER] (B bed) was visited and it was noted that the window air conditioning unit and the resident's television were plugged into a 1363 A relocatable power tap that was plugged into the outlet. The A bed resident's air mattress and television were plugged into a UL listed 1363 A power tap that was plugged into a separate outlet near the A bed. - At 1:50 PM, an examination of the center stairwell revealed that a multiple adapter was daisy - chained to a second multiple adapter. The electrical cord for the resident Wander Guard system was plugged into one of the multiple adapters that was plugged into an outlet in the stairwell. In an interview at the time of the findings, the Maintenance staff member stated that the battery for the Wander Guard system near the door was plugged into the adapter because the battery electrical cord would not reach the outlet. He further stated that he will consult with the electrician to determine whether an additional outlet can be installed. - At 10:55 AM on 9/9/16, a tour of the Rehab room was conducted. A [MEDICATION NAME], a window air conditioner, and the automatic parallel bar machine were plugged into a 1363 A power tap that was plugged into an electrical outlet in the room. In a separate outlet in the room, the computer equipment was plugged into a relocatable power tap that was daisy - chained to a second power tap. The UL rating of the power taps could not be determined due to their position. In a separate outlet on the opposite side of the room an elevating mat table and computer equipment were plugged into a relocatable power tap that was plugged into an outlet. An examination of the power tap revealed the model # E 5. 2000 NFPA 101: 19.5.1, 9.1.2 1999 NFPA 70: 400-8 1999 NFPA 99: 3-3.2.1.2(d)2 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedOctober 13, 2016

1. All extension cords, multiple outlet adapters and daisy chained adapters that were observed during survey were removed. Including those that had high load appliances plugged into power strips. All unauthorized power strips have been removed and replaced with special purpose, relocatable power tops listed as UL 1363A or UL -1.
2. All Maintenance staff, department managers, nursing & housekeeping staff will be in-serviced on the appropriate use of power strips in the nursing home. An audit of the entire building is being completed using a newly created Power Strip Audit Tool. All concerns will be addressed for correct usage.
3. Bi Weekly Environmental rounds will include a check for electrical and mechanical integrity of power strips and receptacles.
Residents and Family will be notified via the Admissions and Social Services Department regarding appropriate use of power strips.
This change will also be reviewed at monthly Resident Council meetings.
Staff will be in serviced upon hire and the mandatory annual review.

4. The efficacy of this practice will be reviewed at monthly Safety Meetings and Quarterly Quality Assurance meetings.
5. The newly hired maintenance director/designee is responsible to ensure that this corrective action is implemented.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: One hour fire rated construction (with o hour fire-rated doors) or an approved automatic fire extinguishing system in accordance with 8.4.1 and/or 19.3.5.4 protects hazardous areas. When the approved automatic fire extinguishing system option is used, the areas are separated from other spaces by smoke resisting partitions and doors. Doors are self-closing and non-rated or field-applied protective plates that do not exceed 48 inches from the bottom of the door are permitted. 19.3.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

Based on observation and interview, the facility did not ensure that hazardous areas were constructed of a one-hour fire rated construction. This was evidenced by the corridor doors to the utility room, boiler room and the soiled linen room that did not latch upon self - closing and/or lacked a self closing device. The findings are: On 9/8/16 and 9/9/16 between the hours of 10:30 AM and 2:30 PM the following issues were noted: - The soiled utility room located on 2 East lacked a self closure device. - The utility room located on the first floor lacked a self closure device. The room was more than 50 sq. ft and contained a floor buffer machine, a janitor's cart, a large chlorine tank, several cans of paint, and the main sprinkler pipes. - The boiler room located on the first floor did not latch upon self-closing. The door rested on the frame and additional assistance was required for the door to latch. In an interview at the time of the findings, the Maintenance staff member stated that self closure devices will be installed on the doors and the hinge on the door to the boiler room will be tightened. 2000 NFPA 101: 19.3.2.1; 8.4.1 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedSeptember 30, 2016

K029
1. Self-closing devices were installed on those doors found during survey walk through.
2. A walk through was completed by Administrator and newly hired maintenance director to ensure that all hazardous area, corridor doors latched upon self-closing device.
3. Environmental rounds completed by Maintenance Director/designee checklist now includes inspection of self-closing doors to hazardous area.
4. All concerns will be addressed at Quarterly Quality Assurance and Monthly Safety Meetings.

ZT1N 415.29:PHYSICAL ENVIRONMENT

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 415.29 Physical environment. The nursing home shall be designed, constructed, equipped and maintained to provide a safe, healthy, functional, sanitary and comfortable environment for residents, personnel, and the public. (h) Ventilating, heating, and air conditioning systems. Such systems shall: (1) be maintained in good repair and shall be operated in a manner which will not allow for the spread of infection and provide for resident health and comfort; and (2) be maintained and operated in such manner that air shall not be circulated from resident isolation rooms, laboratories in which work is done in pathology, virology or bacteriology, autopsy rooms, kitchen and dishwashing areas, toilet and bathrooms, janitors' closets and soiled utility rooms or soiled linen rooms, to other parts of the facility. 713-3.24 - Mechanical systems and equipment 2. All air - supply and air - exhaust systems shall be mechanically operated. All fans serving exhaust systems shall be located at the discharge end of the system. The ventilation rates shown in Table 8 of this subdivision shall be considered as minimum acceptable rates and shall not be construed as precluding the use of higher ventilation rates provided such higher rates do not result in undesirable air velocity in resident -use areas. (d)(2)(ii) The ventilation systems shall be designed and balanced to provide the pressure relationship as shown in Table 8, Pressure Relationships and Ventilation of Nursing Home Facilities, which requires that a bathroom be provided with a minimum total of 10 air changes per hour. The findings are: Based on observation, and staff interview, the facility did not ensure that the exhaust system in tub/shower rooms on resident floors were maintained to provide the minimum air exchanges as per Table 8. This was evidenced by the exhaust fans operating only when the light switches for these areas were turned on. The findings are: On 9/8/16 at 11:20 AM, the shower room located on 2 East, opposite resident room [ROOM NUMBER] was visited and a musty odor was noted in the room. The maintenance staff member tested the exhaust fan in the room and it was noted that the it only operates when the light switch that provides light to the room is turned on. This was also noted in the shower room located on 3 East. The lights in both areas were off at the time the rooms were visited. In an interview at the time of the findings, the Maintenance staff member stated that he will inform the Administrator of the situation noted. 10 NYCRR 711.2 (a)(1) 415.29 (h)(1)(2),(j)(6) 713-3.24(d)(2)(ii)

Plan of Correction: ApprovedSeptember 30, 2016

1310
1. Those exhaust systems that were identified were immediately secured to maintain air exchange.
2. An audit was completed by Administrator and newly hired maintenance director. All of the exhaust fans that were operated with the light switches turned on were identified.
3. A licensed electrician was contracted to install isolated ventilation in those identified exhaust systems.
4. Visual checks of efficacy will be completed by bi weekly environmental rounds. All concerns will be discussed at safety meeting and added to preventive maintenance program.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 9, 2016
Corrected date: October 31, 2016

Citation Details

713 -2.22 - Electrical requirements. (f) Equipment installation in special areas. The electrical circuit(s) to fixed or portable equipment in hydrotherapy units shall be provided with five milliampere ground fault interrupters. The requirements are not met as evidenced by: Based on observation and interview, the facility did not ensure that a ground fault circuit interrupter (GFCI) outlet was provided for the portable hydrotherapy unit (hydrocullator) in the resident Rehab room. The findings are: On 9/9/16 at 10:55 AM, the Rehab room was visited and it was noted that the Hydrocullator in the room was plugged into a relocatable power tap UL rated 1363 A. The power tap was plugged into a standard electrical outlet rather than the required GFCI outlet. In an Interview at the time of the observation, the Maintenance staff member stated that he will inform the Administrator that a GFCI outlet must be installed in the room. 10 NYCRR 713-2.22 (f)

Plan of Correction: ApprovedOctober 6, 2016

1. All extension cords, multiple outlet adapters and daisy chained adapters that were observed during survey were removed. Including those that had high load appliances plugged into power strips. All unauthorized power strips have been removed and replaced with special purpose, relocatable power tops listed as UL 1363A or UL -1.
Any outlets that are in the vicinity of water will have a ground fault circuit interrupter (GFCI) outlet installed.
2. All Maintenance staff, department managers, nursing & housekeeping staff will be in-serviced on the appropriate use of power strips in the nursing home. An audit of the entire building is being completed using a newly created Power Strip Audit Tool. All areas near water will be audited to secure need for GFCI outlets. ALl of those identified power taps will be plugged into GFCI outlets.
3. Bi Weekly Environmental rounds will include a check for electrical and mechanical integrity of power strips, receptacles, proper usage of receptacles, including the need of GFCI outlets
Residents and Family will be notified via the Admissions and Social Services Department regarding appropriate use of power strips.
This change will also be reviewed at monthly Resident Council meetings.
Staff will be in serviced upon hire and the mandatory annual review.

4. The efficacy of this practice will be reviewed at monthly Safety Meetings and Quarterly Quality Assurance meetings.
5. The newly hired maintenance director/designee is responsible to ensure that this corrective action is implemented.