Richmond Center for Rehabilitation and Specialty Healthcare
January 31, 2019 Certification Survey

Standard Health Citations

FF11 483.10(f)(10)(iii):ACCOUNTING AND RECORDS OF PERSONAL FUNDS

REGULATION: 483.10(f)(10)(iii) Accounting and Records. (A) The facility must establish and maintain a system that assures a full and complete and separate accounting, according to generally accepted accounting principles, of each resident's personal funds entrusted to the facility on the resident's behalf. (B) The system must preclude any commingling of resident funds with facility funds or with the funds of any person other than another resident. (C)The individual financial record must be available to the resident through quarterly statements and upon request.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 15, 2019

Citation Details

Based on record review and interview, the facility did not ensure that quarterly statements were provided to the residents. Specifically, one of two residents reviewed for Personal Funds did not receive a quarterly statement in a timely manner, specifically resident #38. The facility's Policy, Procedures and Information entitled Management of Resident's Personal Funds/Personal Allowance was reviewed. It documented under: Procedure the following: #4. A separate accounting for each resident's Personal Income Account, including a written record of all transactions (e.g. deposits, withdrawals, and/or automatic deductions) will be maintained. In addition, quarterly bank statements will be distributed to the resident or his/her legal representative. The finding is: On 01/30/19 a record review was done with the Cashier for resident #38's quarterly statement dated 06/01/18-09/30/18. It was not signed by resident #38. The Quarterly statements dated 10/1/18 through 12/31/18 were reviewed. It documented that the resident withdrew money on the following dates: 10/03/18, 10/15/18, 11/2/18, 11/15/18, 12/03/18 and 12/17/18. The resident's last visit to the Cashier's office was 1/15/19 and it was documented on the receipt retained in the Patient Accounts office that she withdrew money from her account. On 01/23/19 at approximately 11:47 AM resident#38 was interviewed and stated that she has a personal account but the facility is not giving her any statement. On 01/30/19 at approximately 10:01 AM an interview was conducted with the Cashier/Patient Accounts. She stated that resident #38's statement dated 6/1/18-9/30/18 was available on 10/30/18 to be given to the resident. She stated that she had it prepared and when the resident came to the window it slipped her mind to offer it to the resident. She continued to state that resident #38 always takes her quarterly statements. The quarterly statements for 10/1/18-12/30/18 will be ready to distribute on 1/31/19. 415.26(h)(5)(i)

Plan of Correction: ApprovedFebruary 24, 2019

Resident #38 was immediately provided with an up to date statement including all transactions and balance.
The finance department reviewed a list of all residents to ensure all statements were given/sent to residents/family's with corresponding records. all were found to be in compliance.
all finance department employees were in serviced on the importance of compliance with regulation of providing all residents/family's with quarterly financial bank statements in a timely manner. This also requires verification to confirm they have received as per policy and procedure.
A Quality Assurance audit tool was created to ensure compliance with policy and procedure.The tool will be used weekly for one month and monthly thereafter.
The Quality assurance committee will review audits on a monthly basis to ensure compliance and follow up when necessary.
The Administrator/director of finance will review findings of committee and audits to ensure compliance and follow up where necessary.

FF11 483.21(b)(2)(i)-(iii):CARE PLAN TIMING AND REVISION

REGULATION: 483.21(b) Comprehensive Care Plans 483.21(b)(2) A comprehensive care plan must be- (i) Developed within 7 days after completion of the comprehensive assessment. (ii) Prepared by an interdisciplinary team, that includes but is not limited to-- (A) The attending physician. (B) A registered nurse with responsibility for the resident. (C) A nurse aide with responsibility for the resident. (D) A member of food and nutrition services staff. (E) To the extent practicable, the participation of the resident and the resident's representative(s). An explanation must be included in a resident's medical record if the participation of the resident and their resident representative is determined not practicable for the development of the resident's care plan. (F) Other appropriate staff or professionals in disciplines as determined by the resident's needs or as requested by the resident. (iii)Reviewed and revised by the interdisciplinary team after each assessment, including both the comprehensive and quarterly review assessments.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 21, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on record review and interviews the facility did not ensure to the extent practicable, the participation of the resident and the resident's representative(s) the opportunity to participate in their care planning process. Specifically residents stated upon interviews that they were not afforded the right to participate in the planning of their care. This was evidenced in 3 of 5 residents reviewed for care planning. Residents #193, 249 and 262. The facility's policy titled: 'Care Plans, Comprehensive Person -Centered' states at #4, Comprehensive Care Plan will be consistent with the resident's rights to participate in the development and implementation of his/her plan of care, including the right to participate in the planning process. # 5 the resident will be informed of his /her right to participate in his /her treatment; #7 the care planning process will facilitate resident and or representative involvement. The findings are: 1. Resident #193 was admitted to the facility on [DATE]. The Minimum Data Set 3.0 ( MDS) assessment dated [DATE] documented the resident as alert, oriented to time, place and person, and independent with decision making. On 01/24/2019 at 11:00 AM the State Surveyor (SA) conducted an interview with the resident. When asked if he participated in the planning of his care, was he invited to a care plan meeting he responded that he did not recall any meeting. On 01/28/2019 at 10:00 AM during the SA met with the resident and again asked if he recalled meeting with staff regarding his care. He again stated no. A review of the resident progress notes reveals no documentation of resident , presence or absence during the last quarterly care plan meeting. 2. Resident #249 was admitted to the facility on [DATE]. The Minimum Data Set 3.0 (MDS ) assessment dated [DATE] documented the resident as alert, oriented to person, place and time independent with decision making. On 01/28/2019 at 1:49 PM resident the resident was interviewed by the SA. When asked did he participate in the planning of his care he stated no. When asked specifically if facility staff ever invited him to a meeting he stated no. A Review of the interdisciplinary notes revealed a note by the social worker dated 01/4/2019. It documented that a CCP meeting was held and attended by nursing, social services, activities and dietary staff. There was no mention of the resident's presence or any family member. 3. Resident # 262 was admitted to the facility on [DATE]. The MDS assessment dated [DATE] documented the resident as alert, oriented to person, place and time; independent with decision making. The Resident was interviewed on 01/29/2019 at 1:01 PM by the SA. When asked if staff had ever invited him to a meeting to discuss his plan of care, he stated no. A review of the interdisciplinary notes revealed a noted from the social worker dated 01/12/2019 and described as quarterly notes. The note read: mother is supportive and plan is will promote family involvement in care and that resident and family will participate in CCP meetings. There was no further documentation regarding the resident or family being invited to or attending a Care Plan meeting. On 01/30/2019 at 1:20 PM the unit Social Worker (Employee #3) was interviewed. Employee #3 stated that the MDS department has the calendar for the comprehensive care plan meetings. If the resident is alert and oriented she informs them a few days before the meeting. To those who have family involved, she calls them a call on the phone. She had no record of who or when she contacted the family or residents. Employee #3 stated that letters are not sent to either family or residents informing them of the care planning.

Plan of Correction: ApprovedFebruary 24, 2019

New timely care plan meetings were scheduled for residents 193,249 and 262. Residents were informed by social work department.
Residents were presented with invitation letters and date was noted in new resident/family notification log. Social work notes reflect the date.
The social work department conducted an audit of all residents scheduled for care plan meetings for the next month to ensure all residents/families were notified and it was confirmed and documented.
Social workers and care plan coordinators were in serviced on the process and policy and procedures which include: notification process, logging and documentation.
A Quality tool was created to monitor notification of care plan meetings to residents /families, the logging and documentation. The tool will be used monthly.
Quality assurance committee will review on a monthly basis for follow up where necessary.
Administrator will review findings and follow up where necessary.

FF11 483.80(a)(1)(2)(4)(e)(f):INFECTION PREVENTION & CONTROL

REGULATION: 483.80 Infection Control The facility must establish and maintain an infection prevention and control program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of communicable diseases and infections. 483.80(a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: 483.80(a)(1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to 483.70(e) and following accepted national standards; 483.80(a)(2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv)When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi)The hand hygiene procedures to be followed by staff involved in direct resident contact. 483.80(a)(4) A system for recording incidents identified under the facility's IPCP and the corrective actions taken by the facility. 483.80(e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. 483.80(f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 22, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and staff interview, the facility did not ensure that staff implement practices that help to prevent the development and transmission of communicable diseases and infections. Specifically, the practice of hand hygiene procedures during direct resident contact as evidenced in 1 of 3 sampled residents for infection. Resident #72 The facility's policy on Handwashing / hand hygiene revised on 01/2017 states, the facility considers hand hygiene the primary means to prevent the spread of infections. Further stated in the policy; '#1 all personnel shall be trained and regularly inserviced on the importance of hand hygiene in preventing the transmission of healthcare - associated infections; # 6 use an alcohol based hand rub or alternatively soap and water for the following situations: before and after direct contact with residents before and after handling an invasive device, after contact with objects -- medical equipment in the immediate vicinity of the resident, after removing gloves and before and after entering isolation precaution settings. The finding is: Resident #72 was admitted to the facility on [DATE] with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS ) assessment dated [DATE] identified the resident on cognition as severely impaired and completely dependent to staff in all activities of daily living , resident unable to make needs known . On 1/25/2019 at 11:30 AM the resident was observed in her bed with a tracheal tube connected to a ventilator with the proper settings as per physician's orders [REDACTED]. The unit nurse was asked who does the suctioning, and stated Mostly the respiratory therapist. The Respiratory Therapist (Employee #2) was observed entering the room, he took from his pocket a pair of gloves which he donned. Employee #2 then approached the resident and started suctioning the resident. Employee #2 did not practice hand hygiene, wash hands prior to donning gloves and performing suctioning on the resident. Employee #2 was interviewed immediately after the procedure. Employee #2 acknowledged that he didn't wash hands prior to donning gloves and performing suctioning of the resident. On 01 28/2019 at 3:45 PM the Assistant Director of Nursing (RN#3) who is also the educator was interviewed. RN#3 stated, We give annual lectures on hand washing and as often as it is needed. 415.19(b)(4)

Plan of Correction: ApprovedFebruary 24, 2019

Respiratory therapist immediately washed hands thoroughly as per policy and procedure.
therapist was counseled/re-in-serviced on handwashing and technique. The importance re infection control and following policy and procedure for handwashing.
All staff on unit received re in-service on handwashing and technique, the importance of infection control and following policy and procedure.
Facility staff will be re in-serviced on infection control procedures and handwashing techniques.
A quality assurance tool has been created to monitor timely handwashing and compliance with policy and procedure. The tool will be used weekly for one month and monthly thereafter.
The Quality assurance will review the audits monthly to ensure compliance and follow up where necessary.
Administrator and/or director of infection control will review findings to ensure compliance and follow up where necessary.
.



FF11 483.10(i)(1)-(7):SAFE/CLEAN/COMFORTABLE/HOMELIKE ENVIRONMENT

REGULATION: 483.10(i) Safe Environment. The resident has a right to a safe, clean, comfortable and homelike environment, including but not limited to receiving treatment and supports for daily living safely. The facility must provide- 483.10(i)(1) A safe, clean, comfortable, and homelike environment, allowing the resident to use his or her personal belongings to the extent possible. (i) This includes ensuring that the resident can receive care and services safely and that the physical layout of the facility maximizes resident independence and does not pose a safety risk. (ii) The facility shall exercise reasonable care for the protection of the resident's property from loss or theft. 483.10(i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior; 483.10(i)(3) Clean bed and bath linens that are in good condition; 483.10(i)(4) Private closet space in each resident room, as specified in 483.90 (e)(2)(iv); 483.10(i)(5) Adequate and comfortable lighting levels in all areas; 483.10(i)(6) Comfortable and safe temperature levels. Facilities initially certified after October 1, 1990 must maintain a temperature range of 71 to 81F; and 483.10(i)(7) For the maintenance of comfortable sound levels.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 15, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review and staff interviews, the facility did not ensure that a safe clean, comfortable and homelike environment is maintained. Specifically medical equipment were observed not kept clean and sanitary. This was evident in 2 of 4 units . The facility policy of equipment care issued by the environmental services last revised on 08/2012 reads as follows equipment will be maintained and checked daily for repairs before the next shift will use the equipment. Procedures: to ensure that all equipment is clean and in good repair the ERD worker will: B) never use equipment that is dirty i) comply with schedule for routine cleaning of the following -- medical equipment, IV poles and Tube feeding poles and other. The findings are: During the initial tour of the facility on 01/23/2019 at 10:45 am and 11:30 AM the feeding pumps and feeding poles were bserved dirty, both of which were encrusted with dry brownish colored substances and accumulation of dirt on the feeding pumps body, crevices and on the poles. This was observed on the 1st floor ventilator unit in rooms 101,103,105 A ,105C ,a nd 107 and on the 4th floor unit in rooms [ROOM NUMBER]. On 1/23/ the Registered Nurse Manager (RN#1) was interviewed. RN #1 stated The housekeeping staff cleans the poles once a week, and the feeding pumps are wipe clean daily. If the licensed nurses see the feeding pumps dirty, they are supposed to clean and wipe them too. On 01/29/2019 at 4:00 PM The Director of housekeeping (Employee #6) was interviewed. Employee #6 stated, Housekeeping cleans and washes the feeding pump poles on all units once a week. Upon request for the director of housekeeping was unable to provide a log book or schedule for the cleaning of the medical equipment referenced. 415.5(h)(2)

Plan of Correction: ApprovedFebruary 24, 2019

Feeding pump and poles in rooms 101,103,105A,105C,107,422,404 and 405 were immediately cleaned thoroughly according to policy and procedure.
The director of housekeeping conducted thorough rounds to determine if there were additional poles and or feeding tube machines that were dirty. Other poles and feeding tube machines found to be dirty were immediately cleaned thoroughly.
A program of schedule and inspecting, cleaning poles and machines was created and added to policy and procedure.
Housekeeping staff will be in serviced on policy and procedure and proper technique of cleaning equipment.
A Quality Assurance tool was created to monitor timely cleaning and technique of poles and machines. The tool will be used weekly for one month and monthly thereafter.
The Quality assurance committee will review tool monthly and follow up where necessary.
Administrator will review findings to ensure compliance and follow up where necessary.

Standard Life Safety Code Citations

K307 NFPA 101:CORRIDOR - DOORS

REGULATION: Corridor - Doors Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas resist the passage of smoke and are made of 1 3/4 inch solid-bonded core wood or other material capable of resisting fire for at least 20 minutes. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. Corridor doors and doors to rooms containing flammable or combustible materials have positive latching hardware. Roller latches are prohibited by CMS regulation. These requirements do not apply to auxiliary spaces that do not contain flammable or combustible material. Clearance between bottom of door and floor covering is not exceeding 1 inch. Powered doors complying with 7.2.1.9 are permissible if provided with a device capable of keeping the door closed when a force of 5 lbf is applied. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Nonrated protective plates of unlimited height are permitted. Dutch doors meeting 19.3.6.3.6 are permitted. Door frames shall be labeled and made of steel or other materials in compliance with 8.3, unless the smoke compartment is sprinklered. Fixed fire window assemblies are allowed per 8.3. In sprinklered compartments there are no restrictions in area or fire resistance of glass or frames in window assemblies. 19.3.6.3, 42 CFR Parts 403, 418, 460, 482, 483, and 485 Show in REMARKS details of doors such as fire protection ratings, automatics closing devices, etc.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

2012 NFPA 101 19.3.6.3.5* Doors shall be provided with a means for keeping the door closed that is acceptable to the authority having jurisdiction, and the following requirements also shall apply: (1) The device used shall be capable of keeping the door fully closed if a force of 5 lbf (22 N) is applied at the latch edge of the door. (2) Roller latches shall be prohibited on corridor doors in buildings not fully protected by an approved automatic sprinkler system in accordance with 19.3.5.7. Based on observation and staff interview, the facility did not maintain corridor doors free of impediments to keeping the doors fully closed and latched in their frames. This occurred on four out of four floors of the facility. The findings include, but are not limited to: During the life safety portion of the recertification survey on 1/23/2019, between 9:30 am and 1:00 pm, the following corridor doors were noted to be equipped with manual flush bolts, preventing the doors from self-latching while the flush bolt is engaged: 1) Resident rooms on floors 1-4 had a quarter leaf panel equipped with a manual flush bolt at the top and bottom of the panel. The quarter panels did not close completely, and the swinging door was prevented from latching by the manual flush bolts where the bolt was engaged. 2) The telephone closets opening on to the corridors on all four floors. 3)The linen closet opening on to the corridor on the first floor Upon interview concurrent with these findings, the Maintenance Director stated that the facility thought that the doors were compliant in that they could be operated with one motion, using the bottom manual flush bolt, in the event of an emergency. He further stated that the facility would look into having the doors equipped with automatic flush bolts. 2012 NFPA 101 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedFebruary 21, 2019

The director of maintenance surveyed all doors in the facility to determine which did not have required automatic flush bolts including but not limited to resident rooms on all floors , telephone closets and linen closets on all floors.
The facility ordered automatic flush bolts for all doors requiring them. Installation of flush bolts will be initiated when received.
A QA tool will be created to monitor and ensure installation of flush bolts on all doors requiring in a timely manner. Findings will be reviewed by QA committee monthly for follow up wherever necessary.
Administrator will review findings for follow up where necessary.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Categories *Critical care rooms (Category 1) in which electrical system failure is likely to cause major injury or death of patients, including all rooms where electric life support equipment is required, are served by a Type 1 EES. *General care rooms (Category 2) in which electrical system failure is likely to cause minor injury to patients (Category 2) are served by a Type 1 or Type 2 EES. *Basic care rooms (Category 3) in which electrical system failure is not likely to cause injury to patients and rooms other than patient care rooms are not required to be served by an EES. Type 3 EES life safety branch has an alternate source of power that will be effective for 1-1/2 hours. 3.3.138, 6.3.2.2.10, 6.6.2.2.2, 6.6.3.1.1 (NFPA 99), TIA 12-3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

2012 NFPA 99: Chapter 6 Electrical Systems 2012 NFPA 99: 6.1* Applicability. 2012 NFPA 99: 6.1.1 This chapter shall apply to new health care facilities as specified in Section 1.3. 1999 NFPA 99: 3-5.2.2.1* General. Type 2 essential electrical systems are comprised of two separate systems capable of supplying a limited amount of lighting and power service, which is considered essential for the protection of life and safety and effective operation of the institution during the time normal electrical service is interrupted for any reason. These two separate systems are the emergency system and the critical system. The number of transfer switches to be used shall be based upon reliability, design, and load considerations. Each branch of the emergency system and each critical system shall have one or more transfer switches. One transfer switch shall be permitted to serve one or more branches or systems in a facility with a maximum demand on the essential electrical system of 150 kVA (120 kW). 1999 NFPA 99: 3-5.2.2.2 Emergency System. The emergency system shall supply power for the following lighting, receptacles, and equipment: (a) Illumination of means of egress as required in NFPA 101, Life Safety Code (b) Exit signs and exit directional signs required in NFPA 101, Life Safety Code (c) Alarm and alerting systems, including the following: 1. Fire alarms 2. Alarms required for systems used for the piping of nonflammable medical gases as specified in Chapter 4, Gas and Vacuum Systems (d) * Communication systems, where used for issuing instructions during emergency conditions (e) Sufficient lighting in dining and recreation areas to provide illumination to exit ways of 5-foot candles minimum (f) Task illumination and selected receptacles at the generator set location (g) Elevator cab lighting, control, communication, and signal systems **No function other than those listed above in items (a) through (g) shall be connected to the emergency system. 1999 NFPA 99: 3-5.2.2.3 Critical System. (a) General. The critical system shall be so installed and connected to the alternate power source that equipment listed in 3-5.2.2.3(b) shall be automatically restored to operation at appropriate time-lag intervals following the restoration of the emergency system to operation. Its arrangement shall also provide for the additional connection of equipment listed in 3-5.2.2.3(c) by either delayed-automatic or manual operation. (b) Delayed-Automatic Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for delayed-automatic connection to the alternate power source: 1. Patient care areas - task illumination and selected receptacles in the following: a. Medication preparation areas b. Pharmacy dispensing areas c. Nurses' stations (unless adequately lighted by corridor luminaires) 2. Supply, return, and exhaust ventilating systems for airborne infectious isolation rooms 3. Sump pumps and other equipment required to operate for the safety of major apparatus and associated control systems and alarms 4. Smoke control and stair pressurization systems 5. Kitchen hood supply and/or exhaust systems, if required to operate during a fire in or under the hood (c) * Delayed-Automatic or Manual Connections to Critical System. The following equipment shall be connected to the critical system and be arranged for either delayed-automatic or manual connection to the alternate power source: 1. Heating Equipment to Provide Heating for General Patient Rooms. Heating of general patient rooms during disruption of the normal source shall not be required under any of the following conditions: a. *The outside design temperature is higher than +20F (-6.7C), or b. The outside design temperature is lower than +20F (-6.7C) and, where a selected room(s) is provided for the needs of all confined patients, then only such room(s) need be heated, or c. The facility is served by a dual source of normal power as described in 3-4.1.1.1. 2. Elevator Service. In instances where interruptions of power would result in elevators stopping between floors, throw-over facilities shall be provided to allow the temporary operation of any elevator for the release of passengers. (For elevator cab lighting, control, and signal system requirements, see 3-5.2.2.2(g).) (d) Optional Connections to the Critical System. Additional illumination, receptacles, and equipment shall be permitted to be connected only to the critical system. 1999 NFPA 99: 3-5.2.2.4 Wiring Requirements. (a) * Separation from Other Circuits. The emergency system shall be kept entirely independent of all other wiring and equipment. (b) * Receptacles. The cover plates for the electrical receptacles or the electrical receptacles themselves supplied from the emergency system shall have a distinctive color or marking so as to be readily identifiable. Based on observation, document review (i.e., posted electrical panel directories), and staff interview during the recertification survey, the facility was not able to demonstrate that it was provided with an NFPA 99 - Health Care Facilities conforming Type 2 Essential Electrical System, in that Emergency System ( as defined by NFPA 99)- Life Safety Branch wiring was not separated from Critical System wiring. This occurred on two out of four floors of facility. The findings include but are not limited to: During the life safety code portion of the recertification survey the following were noted: 1) Electrical circuit panel EC-3B directory listed life safety circuits 4th floor fire dampers and 2nd floor fire dampers, along with critical loads such as room receptacles, nurse call and room lights and corridor lights. 2) Panel EC-3A directory listed dampers along with various receptacles and nurse call. 3) Panel EC-1A directory listed dampers along with nurse call and various rooms. It was not clear of the room circuits were lights or receptacles. In addition, the conduits for each of these emergency panels entered a shared raceway with non-emergency wiring from normal electrical panels. The facility was unable to demonstrate, at the time of the survey, that normal and emergency wiring was physically separated. Upon interview concurrent with these findings, the Director of Maintenance stated that the facility would look into separating the wiring. 2012 NFPA 99 1999 NFPA 99 10 NYCRR 711.2(a)

Plan of Correction: ApprovedFebruary 21, 2019

Director of maintenance and licensed electrician inspected cited electrical panels to determine definitively where and any additional circuits were wired inappropriately to critical load panel.
The licensed electrician will remove all non critical circuits from critical load panel and reinstall them to other panel. This includes damper circuits for fourth floor and second floor from panel EC-3B, EC-3A and EC-1A.
Director of maintenance tested circuits and replaced directory lists to ensure all matched circuits and directory.
The facility demonstrated that each emergency wiring panel did not share raceway. Separate panels were divide by steel plates. These were unconfirmed during survey. Photographic verification of opened raceway was forwarded to New York State Department of health.
A QA tool was created to confirm directories and follow up on the correct placement of circuits after reinstallation. Tool will be reviewed by QA committee monthly for follow up as necessary.
Administrator will review reports and findings for follow up where necessary.

K307 NFPA 101:SMOKING REGULATIONS

REGULATION: Smoking Regulations Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or compartment where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such area shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 18.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. 18.7.4, 19.7.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 15, 2019

Citation Details

2012 NFPA 101: 19.7.4* Smoking. Smoking regulations shall be adopted and shall include not less than the following provisions: (1) Smoking shall be prohibited in any room, ward, or individual enclosed space where flammable liquids, combustible gases, or oxygen is used or stored and in any other hazardous location, and such areas shall be posted with signs that read NO SMOKING or shall be posted with the international symbol for no smoking. (2) In health care occupancies where smoking is prohibited and signs are prominently placed at all major entrances, secondary signs with language that prohibits smoking shall not be required. (3) Smoking by patients classified as not responsible shall be prohibited. (4) The requirement of 19.7.4(3) shall not apply where the patient is under direct supervision. (5) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (6) Metal containers with self-closing cover devices into which ashtrays can be emptied shall be readily available to all areas where smoking is permitted. Based on observation and staff interview, the facility did not ensure that ashtrays of a safe design with center rests were provided in the smoking area in the second floor smoking room,, nor did the facility ensure that metal containers with self -closing covers. This occurred on one of the four floors of the facility. The findings are: On 1/23/19 at approximately 11:45 am during the recertification survey, ashtrays of a safe design with a center rest were not provided in the smoking room on the second floor. Multiple smoking outposts were provided in lieu of the required ashtrays. The outposts were not configured to allow a resident to put down their cigarette securely. The smoking room also lacked a metal container with self- closing cover devices for the disposal of ashtray contents. In an interview on 1/23/2019 at approximately concurrent with this finding, the Director of Maintenance stated that the facility will get the appropriate ashtrays and metal containers. 2012 NFPA 101: 19.7.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 26, 2019

The facility installed new ashtrays of safe design in all smoking rooms/areas. The ashtrays have center rests that allow residents to put their cigarettes down safely. They are also metal containers and are self closing.

Director of housekeeping inspected all smoking areas to determine the number of ashtrays of safety compliant design would be needed and in what areas of the facility they are needed.
A QA tool was created to inspect and ensure ashtrays were code compliant and installed for safety in all smoking areas.
The QA committee will review results monthly and follow up where necessary.
Administrator will review results and follow up where necessary.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: N/A

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2012 NFPA 101: 19.3.5.5 In Type I and Type II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specified areas where the authority having jurisdiction has prohibited sprinklers, without causing a building to be classified as non-sprinklered. 2012 NFPA 101: 9.7.3.1 In any occupancy where the character of the fuel for fire is such that extinguishment or control of fire is accomplished by a type of automatic extinguishing system in lieu of an automatic sprinkler system, such system shall be installed in accordance with the appropriate standard, as determined in accordance with Table 9.7.3.1. 2012 NFPA 101: Table 9.7.3.1 Fire Suppression System Installation Standards Fire Suppression System Installation Standard Low-, medium-, and high-expansion foam systems NFPA 11, Standard for Low-, Medium-, and High-Expansion Foam Carbon [MEDICATION NAME] systems NFPA 12, Standard on Carbon [MEDICATION NAME] Extinguishing Systems Halon 1301 systems NFPA 12A, Standard on Halon 1301 Fire Extinguishing Systems Water spray fixed systems NFPA 15, Standard for Water Spray Fixed Systems for Fire Protection Deluge foam-water sprinkler systems NFPA 16, Standard for the Installation of Foam-Water Sprinkler and Foam-Water Spray Systems Dry chemical systems NFPA 17, Standard for Dry Chemical Extinguishing Systems Wet chemical systems NFPA 17A, Standard for Wet Chemical Extinguishing Systems Water mist systems NFPA 750, Standard on Water Mist Fire Protection Systems Clean agent extinguishing systems NFPA 2001, Standard on Clean Agent Fire Extinguishing Systems 2009 NFPA 17: 5.7.4 Connection to the Alarm System. The extinguishing system shall be connected to the fire alarm system, if provided, in accordance with the requirements of NFPA 72, National Fire Alarm Code, so that the actuation of the dry chemical system will sound the fire alarm as well as provide the function of the extinguishing system. 2010 NFPA 13: 8.6.3.4 Minimum Distances Between Sprinklers. 2010 NFPA 13: 8.6.3.4.1 Unless the requirements of 8.6.3.4.2, 8.6.3.4.3, or 8.6.3.4.4 are met, sprinklers shall be spaced not less than 6 ft (1.8 m) on center. 8.5.5.2* Obstructions to Sprinkler Discharge Pattern Development. 8.5.5.2.1 Continuous or noncontinuous obstructions less than or equal to 18 in. (457 mm) below the sprinkler deflector that prevent the pattern from fully developing shall comply with 8.5.5.2. 2010 NFPA 13: 8.6.4.1 Distance Below Ceilings. 2010 NFPA 13: 8.6.4.1.1 Unobstructed Construction. 2010 NFPA 13: 8.6.4.1.1.1 Under unobstructed construction, the distance between the sprinkler deflector and the ceiling shall be a minimum of 1 in. (25.4 mm) and a maximum of 12 in. (305 mm) throughout the area of coverage of the sprinkler. Based on observation and staff interview during the recertification survey, the facility was not protected throughout by an approved automatic sprinkler system in accordance with 2012 NFPA 101and NFPA 17, Standard for Dry Chemical Extinguishing Systems, in that the dry chemical extinguishing system in the elevator machine room was not tied into the fire alarm system. In addition, several water based sprinkler heads were found to be installed improperly, This occurred on four out of four floors of the facility. The findings are: 1)On 1/23/2019 at approximately 12:45 pm during the life safety portion of the recertification survey, the dry chemical extinguishing system in the elevator machine room on the roof was noted not tied into the fire alarm system. 2)On 1/23/2019 between 9:00 am and 1:30 pm the following sprinkler heads were found to be improperly installed: a)In room [ROOM NUMBER]B, the Depleted Charts Room, an upright sprinkler head was found installed less than one inch from the ceiling. b)In Storage room [ROOM NUMBER] and room [ROOM NUMBER], a concealed sprinkler head was noted installed on a monolithic, rather than drop ceiling. In addition the head in room [ROOM NUMBER] was noted less than 18 from the top of a light fixture. c)In shower room [ROOM NUMBER] two sprinkler heads were noted to be approximately two feet apart rather than the required 6 feet minimum distance. d)In the second-floor shower room one of the shower stalls lacked a sprinkler head. The shower curtain was solid and would obstruct the spray from the sprinkler head outside the shower stall. In an interview concurrent with this finding, the Director of Maintenance stated that the dry chemical system was not connected to the fire alarm and the facility would contact the installation company to have the issue corrected. He further stated that the non-compliant sprinkler heads would be moved or replaced. 2012 NFPA 101: 19.3.5.1, 19.3.5.5, 9.7.3.1 2009 NFPA 17: 5.7.4 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedFebruary 21, 2019

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** The facility will be requesting a waiver in order to install dry chemical extinguishing system in elevator machine room.
room [ROOM NUMBER]B(Depleted chart room), A new sprinkler head will be installed over 1 inch from ceiling and no more than 12 inches.
Rooms 143, 439, new sprinkler heads will be installed. room [ROOM NUMBER] sprinkler head will be installed more than 18 inches from the light fixture.
room [ROOM NUMBER] (shower room), new sprinkle heads 6 feet apart will be installed .
2nd floor shower room, a new sprinkler will be installed in shower stall. Curtain will be changed so that it does not obstruct the spray from the new shower head sprinkler.

The director of maintenance did a full inspection of every area of the facility including rooms and closets. All were found to be in compliance with sprinkler system codes. A QA tool was created and used to complete the inspection.
The director of housekeeping inspected all shower room curtains to ensure they were not obstructing shower sprinkler heads. Those that were , were immediately replaced. A QA tool was created and used to complete inspection.
The QA committee will review all findings to ensure compliance and follow up where necessary. Findings will be reviewed monthly.
Administrator will review findings for follow up where necessary.

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 2012 NFPA 101 9.7.1.1* Each automatic sprinkler system required by another section of this Code shall be in accordance with one of the following: (1) NFPA 13, Standard for the Installation of Sprinkler Systems (2) NFPA 13D, Standard for the Installation of Sprinkler Systems in One- and Two-Family Dwellings and Manufactured Homes (3) NFPA 13R, Standard for the Installation of Sprinkler Systems in Residential Occupancies up to and Including Four Stories in Height 2012 NFPA 101: 19.3.5.1 Buildings containing nursing homes shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with Section 9.7, unless otherwise permitted by 19.3.5.5. 2010 NFPA 13 26.1* General. A sprinkler system installed in accordance with this standard shall be properly inspected, tested , and maintained by the property owner or their authorized representative in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintenance of Water-Based Fire Protection Systems, to provide at least the same level of performance and protection as designed. 2011 NFPA 25 5.2.1.4 The supply of spare sprinklers shall be inspected annually for the following: (1) The correct number and type of sprinklers as required by 5.4.1.4 and 5.4.1.5 (2) A sprinkler wrench for each type of sprinkler as required by 5.4.1.6 5.3.1.1.1.6* Dry sprinklers that have been in service for [AGE] years shall be replaced or representative samples shall be tested and then retested at 10-year intervals. Based on observation, document review and staff interview during the recertification survey, the facility failed to inspect dry type sprinkler heads at the required intervals and failed to keep a supply of spare dry type sprinkler heads on the premises. This occurred in the basement of the facility. The findings include: During the life safety portion of the recertification survey on 1/23/2019 at approximately 11:00 am, dry type sprinkler heads were noted in the walk -in refrigerators and freezers in the main kitchen. The date that the sprinkler heads were installed could not be determined by direct observation or document review. Upon interview concurrent with this finding the Director of Maintenance stated that he was sure the sprinkler heads were installed greater than ten years ago, and further stated that the heads would be replaced. In addition, on 1/23/2019 at approximately 1:00 pm, an inspection of the store of spare sprinkler heads in the facility basement revealed that no spare dry type heads were stored on the premises. Upon interview concurrent with this finding, the Director of Maintenance stated that spare dry type sprinkler heads would be ordered. 2012 NFPA 101 2010 NFPA 13 2011 NFPA 25 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedFebruary 21, 2019

Director of maintenance surveyed all areas containing dry sprinkler heads to determine the number and areas and dry sprinkler heads to be inspected and installed as required.
The facility retained a licensed vendor to facilitate up to date current inspection and certification of system.
A QA tool was created to monitor timeliness of inspection and instillation of new dry sprinkler heads as necessary. Results will me reported to QA committee monthly for follow up as necessary.
Administrator will review results and follow up wherever necessary.

K307 NFPA 101:SUBDIVISION OF BUILDING SPACES - SMOKE BARRIE

REGULATION: Subdivision of Building Spaces - Smoke Barrier Doors 2012 EXISTING Doors in smoke barriers are 1-3/4-inch thick solid bonded wood-core doors or of construction that resists fire for 20 minutes. Nonrated protective plates of unlimited height are permitted. Doors are permitted to have fixed fire window assemblies per 8.5. Doors are self-closing or automatic-closing, do not require latching, and are not required to swing in the direction of egress travel. Door opening provides a minimum clear width of 32 inches for swinging or horizontal doors. 19.3.7.6, 19.3.7.8, 19.3.7.9

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: January 31, 2019
Corrected date: March 29, 2019

Citation Details

2012 NFPA 101: 19.3.7.8 Doors in smoke barriers shall comply with 8.5.4 and all of the following: (1) The doors shall be self-closing or automatic-closing in accordance with 19.2.2.2.7. (2) Latching hardware shall not be required (3) The doors shall not be required to swing in the direction of egress travel. 2012 NFPA 101: 8.5.4.4 Doors in smoke barriers shall be self-closing or automatic-closing in accordance with 7.2.1.8 and shall comply with the provisions of 7.2.1. 2012 NFPA 101: 7.2.1.15.2 Fire-rated door assemblies shall be inspected and tested in accordance with NFPA 80, Standard for Fire Doors and Other Opening Protectives. Smoke door assemblies shall be inspected and tested in accordance with NFPA 105, Standard for Smoke Door Assemblies and Other Opening Protectives. 2010 NFPA 105: 4.1.1 Fire door assemblies that are intended for use as smoke door assemblies shall also comply with NFPA 80, Standard for Fire Doors and Other Opening Protectives 2010 NFPA 80: 6.3.1.7* Clearances. 6.3.1.7.1 The clearances between the top and vertical edges of the door and the frame, and the meeting edges of doors swinging in pairs, shall be 1?8 in. 1?16 in. (3.18 mm 1.59 mm) for steel doors and shall not exceed 1?8 in. (3.18 mm) for wood doors. . Based on observation and staff interview during the recertification survey, the facility failed to ensure that doors in smoke barriers closed automatically and fully, specifically cross corridor smoke barrier doors had a gap at the meeting edge greater than 1/8. This occurred on three out of four floors of the facility. The findings include: During the life safety portion of the recertification survey on 1/23/2019 it the following pairs of smoke barrier doors were noted to have gaps of greater than 1/8 at their meeting edge: 1) The smoke barrier cross corridor doors by the nurse's station in Unit 3A, and by the elevators in Unit 3B. 2) The cross- corridor smoke barrier doors on the fourth floor. 3) The cross- corridor smoke barrier doors near the nurse's station in Unit 2B. Upon interview concurrent with these findings, the Director of Maintenance stated that the facility would close the gaps in the doors. 2012 NFPA 101 2010 NFPA 105 2010 NFPA 80 10 NYCRR 711.2 (a)

Plan of Correction: ApprovedFebruary 21, 2019

Director of maintenance performed inspection of all remaining smoke barrier corridor doors to determine if there were any gaps. There were none.
Door edges and Astragals were ordered to be installed to smoke doors with gaps.
A QA tool was created to monitor smoke barrier doors. Tool will be used weekly for one month and monthly thereafter.
QA committee will review and monitor results for follow up where necessary.
Administrator will review findings to follow up where necessary.