St Johns Health Care Corporation
November 9, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.60(i)(1)-(3):FOOD PROCURE, STORE/PREPARE/SERVE - SANITARY

REGULATION: (i)(1) - Procure food from sources approved or considered satisfactory by federal, state or local authorities. (i) This may include food items obtained directly from local producers, subject to applicable State and local laws or regulations. (ii) This provision does not prohibit or prevent facilities from using produce grown in facility gardens, subject to compliance with applicable safe growing and food-handling practices. (iii) This provision does not preclude residents from consuming foods not procured by the facility. (i)(2) - Store, prepare, distribute and serve food in accordance with professional standards for food service safety. (i)(3) Have a policy regarding use and storage of foods brought to residents by family and other visitors to ensure safe and sanitary storage, handling, and consumption.

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one of one main kitchen, the facility did not store and prepare food in a safe and sanitary manner. Specific issues included Time/Temperature Controlled for Safety (TCS) foods that were hot holding below 140 degrees Fahrenheit (*F), condensate was dripping on the food containers, and raw TCS foods were stored above ready to eat foods. This is evidenced by the following: Observations conducted in the main kitchen on 11/3/17 between 8:33 a.m. and 10:17 a.m. revealed the following: a. Scrambled eggs were in a pan stacked on top of another pan inside of the steamer. The pan of eggs was not touching the hot water. The temperature of the scrambled eggs was found to be 123*F. In an interview at that time, the Cook stated that the eggs have been there for about 15 minutes and are supposed to hot hold at 140*F. In an interview at that time, the Assistant Dining Services Manager stated that 123*F is not a proper holding temperature for eggs and that the pan should be directly in the hot water when hot holding. b. Bags of parmesan cheese were found stored below raw chicken. In an interview at that time, the Cook stated that they use the parmesan cheese to put on top of spaghetti and things like that. At that time, the Assistant Dining Services Manager stated that the parmesan cheese should be stored above the chicken. c. The condenser line in the walk in meat freezer had approximately 12 areas encased in frozen condensate that had dripped onto a box of chicken. In an interview at that time, the Assistant Dining Services Manager stated that it looks like the condensate had dripped onto the chicken. He said they would have to dispose of the chicken. d. One flat of eggs in the walk in cooler were found stored above a bucket of frosting. In an interview at that time, the Assistant Dining Services Manager stated that the frosting is not cooked before use and that the eggs should not be stored on the rack above the frosting. e. Upon entering the Café area, Resident # 271 was observed at a table eating breakfast. In an interview at that time, the Assistant Dining Services Manager stated that the resident eats breakfast there everyday. The Assistant Dining Services Manager then stated that the resident always gets French toast and a sausage patty. Observations of the steam table in the cafeteria revealed that the items in the steam wells were uncovered. Hot holding temperatures of the items in the steam wells revealed that the sausage patties were hot holding at 111*F, sausage links were hot holding at 110*F, scrambled eggs with ham and cheese were hot holding at 129*F, and the home fries were hot holding at 116*F. In an interview at that time, the Dining Services Team Member working the steam table stated that she did not know where the thermometer was to take food temperatures. The surveyor then asked how they would know if food is hot holding at the correct temperatures, the Assistant Dining Services Manager stated that they should be taking temperatures of food that is hot holding. A review of the facility policy, Food Storage revealed that food is stored a minimum of 6 inches above the floor, 18 inches from the ceiling, and 2 inches from the wall on clean racks or other clean surfaces, and is protected from splashes, overhead pipes, or other contamination (ceiling sprinklers, sewer/waste disposal pipes, vents, etc.), and all freezer units are kept clean and in good working condition at all times. A review of the facility policy, Food Temperatures revealed that all hot food items must be cooked to appropriate internal temperature, held and served at a temperature of at least 140*F. Hot food items may not fall below 140*F after cooking, unless it is an item which is to be rapidly cooled to below 40*F and reheated to at least 165*F prior to serving. Temperatures should be taken periodically to assure hot foods stay above 140*F and cold foods stay below 40*F during the portioning, transporting and delivery process until received by the individual recipient. (14-1.40, 14-1.95, 14-1.100)

Plan of Correction: ApprovedDecember 1, 2017

1:
a. The pan of Eggs was immediately discarded.
b. The bag of parmesan cheese was immediately discarded.
c. The box of chicken was discarded and a work order was put in to maintenance to have condenser line looked at.
d. The eggs were moved and the unopened frosting container was wiped down with sanitizing wipes.
e. All of the hot food items in the cafeteria were discarded upon the temps in the uncovered steam wells being too low.
Fresh batches of eggs with ham and cheese, sausage links, sausage patties, and home fries were made. Each batch was temped to ensure proper safe holding and then held in steamwells covered. We then took temperatures on all hot food in café on the hour to make sure we were maintaining safe hot holding temperatures.
(Dining Assistant Manager 11/9/17)
2.The Lead cook will be conducting weekly audits of kitchen storage and holding temperatures x4 weeeks to monitor for any areas where deficient practice exists. These will be reviewed monthly by the Dining Manger and Dining Practice Partner.
In the Cafeteria, Dining services team members are taking the temperatures of all hot and cold food according to ?Food Temperatures? policy x 4 weeks and staff interviewed for understanding of food temp holding.
These logs and interviews will be reviewed and audited weekly by the Dining Services Assistant Manger who oversees the cafeteria.
A review of these audit results will be reported to qapi 12/20/17.
(Dining Manager, 12/20/17)
2. Policy and procedures will be reviewed and revised for ?Food Storage? and Food Temperatures?. A weekly procedure for overseeing storage and temperatures will be created and the Lead cook, dining assistant manager, and dining manager will be trained on implementation of this procedure.
ALL Dining Services employees will be in-serviced on the following policies, ?Food Storage? and Food Temperatures? and will sign off for attendance records.
(Dining Practice Partner, 1/5/18)
4. Audits results will be reported for compliance with food storage and holding temp in the cafeteria. Any deviation greater than 10% in audit results will be reported to QAPI for further review. (Dining Practice partner, 1/5/18)

FF10 483.10(i)(2):HOUSEKEEPING & MAINTENANCE SERVICES

REGULATION: (i)(2) Housekeeping and maintenance services necessary to maintain a sanitary, orderly, and comfortable interior;

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

Based on observations and interviews conducted during the Recertification Survey, it was determined that for 5 (6 South, 5 South, 4 South, 3 South, and 2 South, ) of 20 resident use floors, the facility did not provide housekeeping and maintenance services necessary to maintain a sanitary, orderly and comfortable interior. Issues included soiled refrigerators, a dirty suction machine, soiled walls around sanitizer dispensers, soiled bathing rooms and wall damage. This is evidenced by the following: 1. Observations conducted on 11/3/17 between 10:52 a.m. and 2:35 p.m. revealed the following: a. The refrigerator in the 6 South Snack Center had dark colored spills and debris inside. In an interview at that time, Nurse Lead #1 stated that she believed that the overnight nursing staff and Certified Nursing Assistant were responsible to clean the refrigerator. Nurse Lead #1 said that the refrigerator did not look clean. b. A Gen Med Aspirator Model A was found outside of the 5 South Soiled Utility room in the corridor, visibly stained and the sputum container had approximately 75 cubic centimeters (cc) to 100 cc of clear liquid with suspended particles in the bottom. In an interview at that time, the Licensed Practical Nurse (LPN) Quality Assurance Coordinator stated that the suction machine was dirty and it should be in the soiled utility room to be cleaned. She said after the suction machines are cleaned, they are supposed to be sent to central supply. c. The refrigerator in the 4 South Snack Center was heavily soiled behind the drawers and in the drawer slides on the bottom of the refrigerator with a blackish/brownish material. In an interview at that time, Nurse Lead #2 stated that she wipes down the refrigerator daily but the dark material does not come off. She said she tried to get it off approximately two months ago. Nurse Lead #2 stated that the refrigerator did not look clean. d. The wall in the 4 South Lounge area was scratched and dented along the left side of the lounge. 2. Observations on 11/6/17 between 7:50 a.m. and 8:33 a.m. revealed the following: a. The refrigerator in the 3 South Snack Center had thick material spilled on the bottom of the refrigerator under the door and also stains in the door racks and below the bottom drawer. In an interview at that time, the LPN Quality Assurance Coordinator said that she was not sure how often the refrigerators were supposed to be cleaned and that she would look for the cleaning schedule. The surveyor then overheard the LPN Quality Assurance Coordinator state to another staff member that the refrigerator was filthy. The LPN Quality Assurance Coordinator later stated that she was unable to find a cleaning schedule. b. The Alcohol Based Hand Rub Dispensers next to Resident Rooms #379 and #371 had spills streaking down the walls which had caused some of the paint to bubble and start to peel off the walls. In an interview at that time, the Manager of Building Services stated that they had painted over the wallpaper. He said the paint was coming off and needed to be repaired. c. In the 2 South Bathroom there were towels and briefs on the floor, and there was a band aid stuck to the wall in the shower stall. In an interview at that time, Nurse Lead #3 stated that the bathroom had not been cleaned yet. When asked if anyone was bathed in this room that day, Nurse Lead #3 stated that she was not sure and had to check. After conferring with staff, Nurse Lead #3 stated that nobody was bathed in the bathroom that day. Nurse Lead #3 stated that ideally the room should be cleaned with in a few minutes after the shower. She said cleaning should include picking up the towels, briefs and the band aid. 3. Observations on 11/8/17 at 2:35 p.m. revealed an approximately 12-inch wide x 24-inch long rectangular cutout in the wall behind a picture frame located in the neighborhood lounge (Reservoir Ground Floor). When interviewed at that time, the Manager of Building Services said it looked like it may have been a fire extinguisher cabinet. (10 NYCRR 415.5(h)(2))

Plan of Correction: ApprovedDecember 1, 2017

1.
a. 6 South refrigerator has been cleaned (ES Supervisor 11/3/17)
b. The suction machine was removed from the floor been cleaned and sanitized per protocol
c. 4 south snack center refrigerator was cleaned (ES Supervisor 11/3/17)
d. The wall on 4 South was repaired and painted
aa. 3 South Snack Center refrigerator and door was cleaned (ES Supervisor 11/6/17)
bb. alcohol based hand sanitizers by room 379 and 371 were painted and repaired (Building services supervisor,1/5/2018)
cc. The 2 south bathroom was cleaned and the towels returned to laundry and briefs disposed of. (ES supervisor, 11/6/17)
The wall will be repaired in the neighborhood lounge and painted by building services
(ES Practice Partner, 1/5/2018)
2.
An audit of all refrigerators will be conducted to review for cleanliness
An audit of all hand sanitizer stations was conducted to review for wall repair and staining
A audit of all bathing areas will be conducted to ensure they are clean
An audit of all wall surfaces will be conducted to review for scratches, painting and staining needs.
The results will be addressed immediately to ensure cleanliness and appropriate wall repair. Completed audits will be reviewed by Assistant Administrator and results shared with QAPI team.
(ES Practice Partner, 12/8)
3. A new procedure has been developed to implement monthly audits of refrigerators on households for cleanliness. (ES practice partner 1/5)
Our existing standard QA environmental/housekeeping audit was reviewed and revised and the sanitizers and wall conditions, and bathrooms will be added to be assessed weekly by ES Partner. A variance of 10% will demonstrate appropriate environmental performance in the organization
(ES Practice partner, 1/5)
4. QAPI committee will review of trends of new audit procedure as well as standard QA audits to ensure ongoing refrigerator cleanliness and sanitizer and wall conditions monitoring as well as bathing room cleanliness. Variance of greater than 10% will be prompt a review of procedures and a root cause.
(ES Practice partner 1/5)

FF10 483.80(a)(1)(2)(4)(e)(f):INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: (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: (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 (facility assessment implementation is Phase 2); (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. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (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: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey, it was determined that for one (Resident #226) of two observations of incontinence care, proper infection control techniques were not followed. Issues involved the lack of glove changing and handwashing during and after incontinence care, the application of barrier cream, and inappropriate application of a protective barrier cream. This is evidenced by the following: The (MONTH) (YEAR) facility policy, Standard and Transmission-Based, included that gloves must be changed and hands washed immediately whenever going from a contamination prone task to a clean task on the same resident and before touching non-contaminated items and environmental surfaces to prevent transfer of microorganisms to the environment. The 8/4/16 facility policy, Personal Care: Procedure for Incontinence Care, included to remove gloves, wash hands, and apply clean gloves after washing and drying the perineal area, after washing and drying the rectal area thoroughly, prior to applying barrier cream, and prior to applying incontinence product. Resident #226 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 8/8/17, revealed that the resident was frequently incontinent of bowel, always incontinent of urine, required extensive assist of staff for personal hygiene, and was totally dependent on staff for toileting needs. The 10/11/17 Key to the Care of Our Elders (directs care) included that the resident was incontinent of bowel and bladder and required one to two staff to assist for toileting needs. During an observation of care on 11/7/17 at 9:08 a.m., the Certified Nursing Assistant (CNA) washed his hands, donned gloves, removed the resident's brief, cleaned the perineum and rectal areas with a small amount of feces noted. Without removing his gloves, the CNA removed the black booties and socks from the resident's feet, then dumped out water, removed his gloves, and washed his hands. At 9:35 a.m., the Licensed Practical Nurse (LPN) entered the room and applied [MEDICATION NAME] balm to the resident's hips and knees. The resident was then rolled on his side towards the wall, and the CNA applied a protective barrier cream (Hydracream) to the rectal area. Without removing his gloves or washing his hands, the CNA rolled the resident on his back and applied the Hydracream to the perineal creases. The CNA then applied the resident's Attends, pulled up his pants, opened a drawer, applied socks, applied black booties, emptied the wash basin and rinsed it, then removed his gloves, lowered the bed, and then brushed the resident's teeth. Interviews conducted on 11/7/17 included the following: a. At 10:03 a.m., CNA #1 said that he should have changed his gloves and washed his hands after cleaning feces from the rectal area, after applying butt cream, and before applying cream to the perineal area because the rectal area is dirty and he could have had feces on his gloves. CNA #1 said he was nervous and would not usually have done what he did. b. At 10:26 a.m., the LPN said she expected staff to remove their gloves and wash their hands after completing care and before applying the brief. The LPN said that staff must always apply the barrier cream to the perineum first and then the rectal area. The LPN said staff are to remove their gloves and wash their hands after applying the barrier cream to each area and before touching anything else because that is a dirty area and there may be cream on the gloves. During an interview on 11/9/17 at 10:33 a.m., the Infection Control Nurse said that she would expect staff to wear gloves and perform urinary incontinence care from front to back ensuring that the area is clean and then dried. She said staff should remove gloves, wash hands, and then put on new gloves to clean the rectal area from front to back. Staff would then remove their gloves, wash their hands, put on new gloves, apply barrier cream to the perineal area first then the rectal area, then remove gloves and wash hands before touching anything else in the environment. (10 NYCRR 415.19(b)(4))

Plan of Correction: ApprovedDecember 1, 2017

1. The CNA was counseled on proper incontinence care and infection control procedures by his supervisor.
Date:11/9/17 Responsible: Neighborhood Administrator
2. Names of residents who are incontinent were reviewed with staff on all floors. Incontinence care and infection control procedures were reviewed with staff on all floors. Date: 1/5/18 Responsible: ADON
3. Policies and Procedures on Incontinence Care and Infection Control related to incontinence were reviewed and updated. All nursing staff were re-educated on these policies and procedures. Date: 1/5/18 Responsible: ADON
4. Audits of incontinence care and infection control have been and will continue to be completed monthly. Issues identified needing immediate attention will be brought to the attention of the supervisory nurse. Audit results will be reported to he QAPI Committee for review and follow up as indicated. Date: 1/5/18 Responsible: ADON
Directed Plan of Correction:
The QAPI Committee met on 11/21/2017 at 11:00 a.m. The following was discussed:
Potential causative factors: The CNA stated that he became nervous, and although he was able to verbalize the correct procedure, he failed to follow the procedure while being watched by the surveyors. It was determined that staff are not observed frequently enough to allay the nerve factor.
To remedy this root cause, regularly scheduled observations of direct care providers (in addition to completing standard quality audits) would address nervousness on the part of caregivers, as well as identify any aberration in procedure or technique. These observations will be scheduled and implemented biannually for all direct care providers, with the first observation completed for all direct care employees by (MONTH) 5, (YEAR).
A routine trigger signaling an evolving problem would be a 10% unfavorable variance in the bi-annual observations occurring for each direct care staff member. Another trigger would be a 10% unfavorable variance in standard QA audit results from incontinence care. Results will be reported to and discussed at the QAPI Committee meeting monthly. Results will be reported to the QAPI Committee for review and follow up as indicated.
(Date: 1/5/18 Responsible: ADON)
Directed Inservice Program:
The classroom training for all direct care employees will revolve around St. (NAME)'s Home's evidenced-based procedures for incontinence care and infection control as developed by ProCare consultant(NAME)J. Turano, R.N., BSN.

The dates of the scheduled training sessions for nursing staff are: 12/5,12/8,12/9,12/12, 12/13, 12/20, and 12/27.
The name of the consultant instructor who will conduct these programs is:(NAME)J. Turano, R.N., BSN
The mechanism for monitoring and evaluation of the effectiveness of the directed in-service programs will be administration of pre-and post-tests for all direct care staff with 90% accuracy.
In addition: A review of ongoing direct care employee observation Audit results with no more than 10%varience
Standard monthly QA audits with no more than 10% variance.
Date: 1/5/18 Responsible: ADON

FF10 483.10(g)(10)(i)(11):RIGHT TO SURVEY RESULTS - READILY ACCESSIBLE

REGULATION: (g)(10) The resident has the right to- (i) Examine the results of the most recent survey of the facility conducted by Federal or State surveyors and any plan of correction in effect with respect to the facility; and (g)(11) The facility must-- (i) Post in a place readily accessible to residents, and family members and legal representatives of residents, the results of the most recent survey of the facility. (ii) Have reports with respect to any surveys, certifications, and complaint investigations made respecting the facility during the 3 preceding years, and any plan of correction in effect with respect to the facility, available for any individual to review upon request; and (iii) Post notice of the availability of such reports in areas of the facility that are prominent and accessible to the public. (iv) The facility shall not make available identifying information about complainants or residents.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: November 9, 2017
Corrected date: December 15, 2017

Citation Details

Based on observations and an interview conducted during the Recertification Survey, it was determined that the facility did not ensure that the most recent survey results conducted by the State and Plan of Correction were posted and accessible for resident and visitor viewing. Specifically, survey results and the Plans of Correction for Abbreviated Surveys had not been posted for review since the last Recertification Survey (8/31/16). This is evidenced by the following: During observations made on 11/7/17 at 3:55 p.m., the New York State Survey results posted did not include the Statement of Deficiencies and Plan of Correction from the Abbreviated Surveys dated 10/26/16, 1/23/17, 2/15/17, and 5/9/17. During an interview on 11/8/17 at 11:06 a.m., the Administrator stated the results of the New York State surveys are in a binder in the front lobby. The Administrator said that she is responsible for updating the binder and had not looked at the binder recently. (10 NYCRR 415.3(1)(c)(1)(v))

Plan of Correction: ApprovedDecember 1, 2017

1. The survey binder was updated with abbreviated surveys from (YEAR) and past 3 years added to ensure compliance with new regulation.
(Administrator, 11/8/17)
2. A policy was written for administrator to review sod on hcs site prior to qapi meetings to ensure all final approves statement of deciciiency are printed and in the binder for easy viewing.(Administrator 12/15/17)
3. The qa agenda was amended to have a reconciliation of hcs sod and the binder to be reported at each qa meeting (Administrator, 12/17, 2/18, 5/18, 8/18, 11/18)

FF10 483.21(b)(3)(ii):SERVICES BY QUALIFIED PERSONS/PER CARE PLAN

REGULATION: (b)(3) Comprehensive Care Plans The services provided or arranged by the facility, as outlined by the comprehensive care plan, must- (ii) Be provided by qualified persons in accordance with each resident's written plan of care.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 562), it was determined that for one(Resident #439) of four residents reviewed for reviewed for nutrition, facility staff did not consistently provide care and services per the plan of care. The issues involved the lack of consistent staff assistance with meals and the lack of consistently being served fortified hot cereal or fresh fruit cup at breakfast. This is evidenced by the following: Resident #439 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. The Minimum Data Set Assessment, dated 10/29/17, revealed the resident had severe cognitive impairment, required extensive assistance of one staff member for eating and was on hospice. The Nutrition Assessment, dated 10/30/17, revealed that the resident required total assistance with meals, received Ensure with meals, and super cereal with breakfast. The Care Plan, dated 10/30/17, for Activities of Daily Living, directed to please sit with me during meals to assist and encourage me to eat and drink because I can be easily distracted with my dementia. The Care Plan for Nutrition, dated 11/2/17, included to refer to diet roster for specific meal set up instructions, offer nutritional supplements per nursing Key to the Care of our Elders, and provide super cereal with breakfast. The Key to the Care of our Elders Card, updated 11/5/17, directed to sit with and feed the resident in the dining room, super cereal with breakfast, Ensure Plus with meals, offer frequent snacks during the day, and fresh fruit cup every morning. On 11/3/17 at 9:00 a.m., a family member said staff told her that a red placemat program was in place. She said the red placemat was used to identify residents who need help with eating. Observations and interviews conducted on 11/7/17 included the following: a. At 8:44 a.m., the resident was in the dining room, sitting alone at a table. She was holding an empty cup and when asked what she had, she was unable to answer. The interior of the cup was dry with no visible fluid. There was no red placemat observed on the table. b. At 8:48 a.m., CNA #1/Shahbaz said the resident needs total assistance for eating but can feed herself when she wants. At that time, there was no staff assisting the resident. c. At 8:58 a.m., the resident was observed with a full bowl of super cereal on the table. There were no staff members assisting her with breakfast. d. At 9:00 a.m., the resident fed herself a spoonful or two of super cereal. She was nodding her head back and forth towards other residents but was not engaged in conversation. e. At 9:11 a.m., CNA #1/Shahbaz pulled up a chair and sat next to the resident. The resident was using her spoon to spread her cereal onto her napkin. f. At 9:21 a.m., CNA#1/Shahbaz left the table, and the resident fed herself several bites of super cereal. g. At 9:26 a.m., CNA#1/Shahbaz returned to the resident with a plate of food, but the resident was not eating. CNA#1/Shahbaz brought the spoon to the resident's mouth but the resident was keeping her lips closed. h. At 9:38 a.m., CNA #1/Shahbaz offered a forkful of egg and sausage to the resident. The resident kept her lips shut. CNA#1/Shahbaz laughed and said, I'm done, placed the fork on the plate, got up and walked away. The resident ate a bite of toast, several spoonfuls of super cereal, and none of the eggs or sausage. The resident did not receive or was not offered a fruit cup. i. At 9:41 a.m., CNA #1/Shahbaz said the resident does not like to be fed and refuses. Observations and interviews conducted on 11/9/17 included the following: a. At 8:25 a.m., the resident was sitting in the dining room, alone at a table, with no red placemat. There was a small bowl of food next to her but there was no beverage on the table. b. At 8:28 a.m., Licensed Practical Nurse (LPN) #2 entered the dining room and gave the resident a spoonful of food which was identified as yogurt. LPN #2 said to the resident that is pretty good, now you go ahead and eat it. The LPN then left the dining room. c. At 8:30 a.m., the resident fed herself a spoonful of yogurt. There was only one CNA in the dining room with five residents. d. At 8:36 a.m., the resident was feeding herself yogurt, there was no staff assistance, and no one was feeding or encouraging the resident. There was no beverage or fresh fruit cup set in place for her. At 8:40 a.m., the resident had eaten all the yogurt. e. At 8:53 a.m., CNA #1 had set a plate of breakfast food in front of the resident and was hurrying back and forth from the kitchen, trying to get food out to other residents. f. At 8:58 a.m., the resident was trying to feed herself some scrambled eggs. She pushed the eggs around on her plate and a big amount landed on her napkin and on her leg. There were two pieces of toast and two cut up sausage links, which she did not touch. g. At 9:02 a.m., CNA #1 passed by the resident, looked at her and said okay and left. h. At 9:05 a.m., the napkin landed on the floor with a big chunk of scrambled eggs lying next to it. i. At 9:20 a.m., the resident had picked up all four pieces of toast, squishing them into her palm. She was pushing sausage pieces around the plate. There were no beverages on the table for the resident. j. At 9:28 a.m., a Registered Nurse (RN) said that she had no idea about the red placemat program. At that time, CNA #1 said she did not know what the program was either. CNA #4 said that she had worked at the facility for many years and had heard about the red placemat program, but she was not sure what it was. She thought maybe it was for dementia residents. The RN and CNA #1 reviewed the Diet Notebook and when asked about the service of a fresh fruit cup, CNA #1 said strawberries had been sliced into the yogurt. CNA #1 said she had not served super cereal. The RN then asked for something warm to give the resident. She sat down next to the resident and looked at the floor. The RN said she thought the resident had eaten the egg but there was a lot of egg on the floor. k. At 9:33 a.m. when asked, CNA #1 said that the resident had not been served super cereal. She did not know if the super cereal had even been provided. CNA #1 then looked at the steam table and found a small pan of super cereal, portioned it up, and brought it to the RN to feed to the resident. l. At 10:43 a.m., a RN/Manager (RNM) and neighborhood Administrator when asked, both said that staff are supposed to sit with the resident during meals. The RNM said the resident needed the assistance of one for eating/feeding. The RNM said staff should be close and encourage the resident to eat. The RNM said she did not know about the red placemat program but the Clinical Leader (who was out sick that day) would know more about that. She said maybe she told the family about it. The RNM and Administrator said they did not know why some CNAs knew about the program and others did not. The RNM said she thought the red placemat program had been talked about but not implemented yet. (10 NYCRR 415.11(c)(3)(ii))

Plan of Correction: ApprovedDecember 1, 2017

1. The RN Nursing Operations Specialist assisted Resident #439 with completion of breakfast on that date. Follow up disciplinary action for the employee referenced will occur for acting outside of our brand characteristics SJH values
Date: 12/15/17 Responsible: RN Nursing Operations Specialist
2. Other residents who require assistance with eating were identified and audits will be completed for dining practices aligning with meal assistance and meal completion and associated documentation. Any findings requiring immediate correction will be brought to the attention of the supervisory nurse.
Date: 11/9/17 Responsible: ADON
3. The Policies and Procedures for Dining Practices and Providing Feeding Assistance have been reviewed and updated. A meal completion monitor will be completed at every meal to document the amount of food and fluids consumed by each resident. All nursing staff are being re-educated and completing competencies on dining practices, to include serving required food and providing required assistance within our brand characteristics. Date: 1/5 (YEAR) Responsible: ADON
4. Audits have been and will continue to be completed monthly on dining practices, meal assistance and meal completion and associated documentation. Any findings requiring immediate correction will be brought to the attention of the supervisory nurse. Audit results are reported to the QAPI Committee for discussion and follow up as needed. Date: 1/5/18 Responsible: ADON

Standard Life Safety Code Citations

K307 NFPA 101:AISLE, CORRIDOR, OR RAMP WIDTH

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for 10 (1, 2, 3, 5, 6-South, 2, 3, 4, 5-Reservoir, and ground floor 1960 building) of 20 resident use floors, the facility did not properly maintain corridor width. Specifically, chairs were stored in corridors and were not properly secured and/or projected more than 24-inches into the required corridor width, and egress pathways were restricted to less than 4-feet of usable width. The findings are: 1. Observations on 11/3/17 between 11:19 and 1:24 p.m. revealed the following: a. On 6 South between Resident Rooms #688 and #681 there was a love seat and two chairs in the corridor which projected approximately 2 feet 10 inches into the 8-foot corridor. In that same location, there were two tables that were not affixed to the wall or floor. In an interview at that time, the Manager of Building Services stated that he was not aware of the 2-foot requirement for furniture in the corridors. b. On 6 South next to Resident room [ROOM NUMBER] there was an arm chair and a table which protruded greater than 2 feet into the 8 foot corridor. In that same location there was a smaller table which protruded less than 2 feet into the corridor but was not affixed to the floor or wall. c. On 6 South next to Resident room [ROOM NUMBER] there were two reclining chairs which protruded greater than 2 feet into the 8 foot corridor. d. On 6 South next to Resident room [ROOM NUMBER] there was an arm chair which protruded greater than 2 feet into the 8 foot corridor. e. On 5 South across from Resident room [ROOM NUMBER] there was a wooden chair that protruded greater than 2 feet into the 8 foot corridor. 2. Observations in the presence of the Manager of Building Services on 11/6/17 from 8:45 a.m. to 11:20 a.m. revealed the following: a. There were stationary chairs in the egress corridor in the following locations: across from Resident Rooms #511, #407, #433, #323, #314, #220, (Reservoir Building). None of the chairs were affixed to the floor or wall, and the corridors were 8-feet wide. b. There were two stationary chairs on opposite sides of the egress corridor outside Resident Rooms #220 and #221 (Reservoir Building), leaving approximately 3-feet of usable width. c. There were several chairs, a night stand, an overbed table, and a file cabinet stored in front of the exit door from the ground floor environmental services room (1960 building) leaving approximately 18 to 24-inches of usable width. d. On 3 South next to Resident room [ROOM NUMBER] there was an arm chair that protruded 2 feet 1 inch into the 8 foot corridor wall and was not affixed to the floor or wall. e. On 3 South next to the smoke barrier doors on the Resident Lounge side of the unit there was a love seat which was protruding 3 feet 3 inches into the 8 foot corridor. f. On 2 South across from the interdisciplinary office, there was an arm chair which was protruding 2 feet 3 inches into the 8 foot corridor. g. On 1 South across from the Medication Room, there was a wooden bench and a table which both protruded approximately 1 feet 9 inches into the 8 foot corridor which were not affixed to the floor or wall. h. On 1 South next to the Lounge, there was a padded chair which reduced the usable width of the 8 foot corridor to 5 feet 7 inches. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.3.4(5), 19.2.1, 7.3.4.1.2)

Plan of Correction: ApprovedDecember 6, 2017

1. The identified items protruding greater than 24 inches into the 8 foot corridor will be removed from those locations, all remaining items will be affixed to the floor or walls by Building Services technicians and/or contractors.
Manager of Building Services 12/29/2017
2. Building Services and/or Protective Services will inspect 100% of the facility similar situations. Any findings will be corrected as described above and reported to the Manager of Building Services for documentation and correction.
Manager of Building Services 12/29/2017
3. A policy will be written and building services, protective services, neighborhood leadership and housekeeping staff educated on maintaining unobstructed corridor widths.
Visual inspections will be added to the regular protective services safety and building services floor tours. Any issues will be corrected and reported to the Director of Facilities.
Director of Facilities & Environmental Services Practice partner 1/5/18
4. Building Services and/or Protective Services will perform regular tour inspections and special inspections of areas receiving any now or additional furniture items. Any issues will be corrected and reports made to the QA.
Director of Facilities 1/5/18

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

REGULATION: Electrical Equipment - Testing and Maintenance Requirements The physical integrity, resistance, leakage current, and touch current tests for fixed and portable patient-care related electrical equipment (PCREE) is performed as required in 10.3. Testing intervals are established with policies and protocols. All PCREE used in patient care rooms is tested in accordance with 10.3.5.4 or 10.3.6 before being put into service and after any repair or modification. Any system consisting of several electrical appliances demonstrates compliance with NFPA 99 as a complete system. Service manuals, instructions, and procedures provided by the manufacturer include information as required by 10.5.3.1.1 and are considered in the development of a program for electrical equipment maintenance. Electrical equipment instructions and maintenance manuals are readily available, and safety labels and condensed operating instructions on the appliance are legible. A record of electrical equipment tests, repairs, and modifications is maintained for a period of time to demonstrate compliance in accordance with the facility's policy. Personnel responsible for the testing, maintenance and use of electrical appliances receive continuous training. 10.3, 10.5.2.1, 10.5.2.1.2, 10.5.2.5, 10.5.3, 10.5.6, 10.5.8

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Life Safety Code Survey, it was determined that for two of four patient care related electrical equipment, the facility did not provide maintenance in accordance with manufacturer's specifications. Specifically, tubing was not recently changed on an oxygen concentrator and a suction machine was dirty and lacked a maintenance manual. The findings are: 1. Observations in the presence of the Manager of Building Services on 11/7/17 at approximately 9:35 a.m. revealed a New Life Elite AirSep oxygen concentrator running in Resident room [ROOM NUMBER] (Reservoir Building). The plastic tubing and container with water attached to the concentrator was marked with a date of 9/13/17. In an interview at that time, a staff member stated that the resident only uses the concentrator as needed so they do not change the tubing as much. Further observations on 11/8/17 at 3:20 p.m. revealed the tubing to the same oxygen concentrator in room [ROOM NUMBER] was marked with a date of 9/13/17, and the humidifier bottle was marked with a date of 11/7/17. When interviewed at that time, the Registered Nurse said the tubing should be changed weekly even if the order was as needed. 2. Observations on 11/3/17 at approximately 1:34 p.m. revealed a Gen Med Aspirator Model A was located outside of the fifth floor South building soiled utility room in the corridor and was visibly stained. The sputum container had approximately 75 cubic centimeters (cc) to 100 cc of clear liquid with suspended particles in the bottom of it. In an interview at that time, the Licensed Practical Nurse, Quality Assurance Coordinator stated that the suctin machine was dirty and it should be in the soiled utility room to be cleaned. She said after the suction machines are cleaned, they are supposed to be sent to central supply. In an interview on 11/8/17 at 8:55 a.m., the Manager of Building Services stated that central supply could not find a maintenance manual for the suction machine. The 2012 edition of NFPA 99, Health Care Facilities Code, states: A permanent file of instruction and maintenance manuals shall be maintained and be accessible. Service manuals, instructions, and procedures provided by the manufacturer shall be considered in the development of a program for maintenance of equipment. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 99: 10.5.3.1.2, 10.5.6, 10.5.6.1.1)

Plan of Correction: ApprovedDecember 6, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1.
Item #1, The O2 tubing on the New life Elite AirSep oxygen concentrator in resident room [ROOM NUMBER] was replaced with new tubing by house staff.
Item #2, The Gen Med Aspirator Model A suction machine located outside of the fifth floor South building soiled utility room was removed permanently from service and replaced with a newly purchased unit by Central Supply staff.(11/9/17)
2. The facility will review maintenance protocol O2 tubing, suction machines and audit all in house equipment for similar issues. Any findings will be corrected and will be reported to the Managers of CSR and Building Services for documentation and/or repair.
Manager of Building Services 12/29/2017
3. A policy and procedure for PCRE inspection and preventative maintenance will be created and implemented. Manuals will be obtained and maintained for all applicable equipment procured by CSR and/or Building Services.
All maintenance employees and CSR team members will be trained on the new policy and procedure.
Director of Facilities 12/29/2017
4. Monthly
Building Services staff will perform regular monthly inspections PCRE according to the maintenance manual. Audit findings will be corrected and a summary shared with QA.
Director of Facilities 1/5/18

K307 NFPA 101:SLEEPING SUITES

REGULATION: Sleeping Suites Occupants shall have exit access to a corridor or direct access to a horizontal exit. Where greater than or equal to 2 exits are required, one exit access door may be to a stairway, passageway or to the exterior. Suites shall be provided with constant staff supervision. Staff shall have direct visual supervision of patient sleeping rooms, from a constantly attended location or the room shall be provided with an automatic smoke detection system. Suites more than 1,000 square feet shall have 2 or more remote exits. One means of egress from the suite shall be to a corridor and one may be into an adjacent suite separated in accordance with corridor requirements. Suites shall not exceed the following size limitations: * 5,000 square feet if the suite is not fully smoke detected or fully sprinklered * 7,500 square feet if the suite is either fully smoke detected or fully sprinklered * 10,000 square feet if the suite is both fully smoke detected and fully sprinklered and the sleeping rooms have direct supervision from a constantly attended location Travel distance between any point in a suite to exit access shall not exceed 100 feet and distance to an exit shall not exceed 150 feet (200 feet if building is fully sprinklered). 18.2.5.7.2, 19.2.5.7.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for 1 (Reservoir second floor) of 20 resident use floors, the facility did not properly maintain resident sleeping suites. Specifically, a resident suite was created and there were less than two exits from the suite. The findings are: Observations in the presence of the Manager of Building Services on 11/7/17 at approximately 10:20 a.m. revealed a wall across the corridor separating the west end of the reservoir building second floor between Rooms #216 and #215. When interviewed at that time, the Manager of Building Services said that the wall was put up to create an area for a resident who requires 1:1 staff care. Further observations revealed the suite includes Rooms #216 through #222 and only room [ROOM NUMBER] is occupied. The newly created suite was greater than 1,000 square feet and included only one marked exit, which leads through the cross-corridor smoke barrier doors between Rooms #222 and #223. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.5.7.2, 19.5.7.2.2(A))

Plan of Correction: ApprovedDecember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. The identified issue of having less than two exits from the suite created on Reservoir second floor will be corrected by adding a marked exit door into the wall in the corridor by room [ROOM NUMBER]. This will be done by Building Services technicians and/or contractors.
Manager of Building Services 12/29/2017
2. Building Services will inspect 100% of the facility for similar situations. Any findings will be reported to the Manager of Building Services for documentation and correction.
Manager of Building Services 12/29/2017
3. Contractor and maintenance protocols will be reviewed, and enforced to prevent any future exiting issues. All work performed by contractors or in-house staff will be audited by the Director of Facilities.
Director of Facilities 12/29/2017
4. Building Services manager will perform post inspections of any new work for similar issues. Any findings will be corrected and reports made to the QA as necessary.
Director of Facilities 1/5/18

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the Life Safety Code Survey, it was determined that for 2 (Hastings first floor and Reservoir first floor) of 20 resident use floors, the facility did not properly maintain the sprinkler system. Specifically, an electrical room lacked sprinkler protection and did not have a proper fire rating, and there was combustible storage beneath a canopy that lacked sprinkler protection. The findings are: 1. Observations in the presence of the Manager of Building Services on 11/6/17 at approximately 1:30 p.m. revealed an electrical room (with a small transformer labeled T601) next to Resident room [ROOM NUMBER] (Hastings first floor) that was not provided with sprinkler protection. Further observations revealed multiple unsealed openings through the walls in this room near the ceiling level, and the door to the room was marked with a tag stating 3/4-hour fire rating. Additionally, there was a ventilation duct supplying cool air to the room and there was no fire rated damper present. In an interview at that time, the Manager of Building Services stated that the room and transformer might have been added on. 2. Observations in in the presence of the Manager of Building Services on 11/7/17 at approximately 1:10 p.m. revealed the following items stored outside the Reservoir Building first floor loading dock: three pallets of boxes containing upholstered chairs, several stacked plastic crates, and dozens of broken pieces of wooden pallets. The canopy for the loading dock was not protected by sprinklers. The 2010 edition of NFPA 13, Standard for the Installation of Sprinkler Systems, states: 1) Sprinklers shall be installed under roofs, canopies, porte-cocheres, balconies, decks, or similar projections greater than 2-feet (0.6 m) wide over areas where combustibles are stored. 2) Sprinklers shall not be required in electrical equipment rooms where all of the following conditions are met: (1) The room is dedicated to electrical equipment only. (2) Only dry-type electrical equipment is used. (3) Equipment is installed in a 2-hour fire-rated enclosure including protection for penetrations. (4) No combustible storage is permitted to be stored in the room. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.5.1, 9.7.1.1,; 2010 NFPA 13: 8.15.7.5, 8.15.10.3)

Plan of Correction: ApprovedDecember 6, 2017

1. The identified issue detailed in #1 will be corrected with the addition of a sprinkler system by licensed sprinkler contractors. The identified issue detailed in #2 will be corrected by clearing and maintaining the space under the canopy free of combustible materials by Purchasing, Building services and Protective services staff.
Manager of Building Services 12/29/2017
2. Building Services and/or certified sprinkler inspectors will inspect 100% of the facility for similar issues with sprinkler system coverage. Any findings will be reported to the Manager of Building Services for documentation and correction.
Manager of Building Services 12/29/2017
3. Construction and renovation practices will be reviewed, updated if needed and enforced to prevent future sprinkler system coverage issues. All work proposed construction plans by contractors or in-house staff affecting sprinkler locations will be audited by the Manager of Building Services.
Director of Facilities 12/29/2017
4.
Building Services will inspect all new construction or renovation projects for proper sprinkler system coverage. Any findings will be corrected and reports made to the QA as necessary.
Director of Facilities 1/5/18

K307 NFPA 101:STAIRWAYS AND SMOKEPROOF ENCLOSURES

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

Based on observations and an interview conducted during the Life Safety Code Survey, it was determined that for three (South building West, Reservoir building West, 1960 building West) of ten exit stair enclosures, the facility did not properly maintain spaces within smoke-proof enclosures. Specifically, there was storage of items within an exit stairwell and rooms opening into stairways had combustible storage and/or propped doors. The findings are: 1. Observations on 11/3/17 at approximately 11:25 p.m. revealed a penthouse which opens into the West Exit Stairwell in the South Building. Inside the penthouse there were oxidizing chemicals and a pail full of dirty rags. In an interview at that time, the Manager of Building Services stated that garbage is from the repairs and that they are getting ready to repair a shaft in an air handler. 2. Observations in the presence of the Manager of Building Services on 11/6/17 at approximately 2:15 p.m. revealed two cardboard boxes containing a washer and dryer and a dishwashing machine that were stored in a short corridor at the top of the 1960 building, which opens directly into the west stairwell above the third floor. 3. Observations in the presence of the Manager of Building Services on 11/7/17 at approximately 11:08 a.m. revealed a cart with metal folding chairs, four wooden blocks, and two folding tables that were stored in the exit stair enclosure of the 1960 building at the ground floor level adjacent to the courtyard. The exit was marked as the pathway leading up from the basement of the 1960 building near the boiler room. 4. Observations on 11/9/17 at approximately 10:10 a.m. revealed the door at the top of Reservoir West stairwell was propped open with sheets of plywood and blue metal scaffolding. The door was equipped with a self-closing device and separated the exit stairwell from a small corridor leading to the roof. Additionally at that location, there was another door between the small corridor and a mechanical room, which was propped open by a gray 5-gallon bucket. The door was marked with a sign that read BE SURE DOOR IS CLOSED AND L(NAME)KED WHEN YOU LEAVE! At the time of the observations there were no staff members present in those areas. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.2.1, 7.1.3.2.1(8, 9c), 7.2.2.5.1.1, 7.2.2.5.3, 7.2.2.5.3.1, 7.2.2.5.3.2)

Plan of Correction: ApprovedDecember 6, 2017

1. a. The chemicals and pail full of dirty rags was removed from the west Exit Stairwell in the South Building
b. The two cardboard boxes containing a washer and dryer and a dishwashing machine that were stored in a short corridor at the top of the 1960 building were relocated
c. The cart with metal folding chairs, four wooden blocks, and two folding tables that were stored in the exit stair enclosure of the 1960 building
d. The Reservoir West stairwell was propped open with sheets of plywood and blue metal scaffolding was closed and items relocated
Manager of Building Services 11/9/17
2. Building Services will inspect 100% of the facility for similar situations. Any findings will be corrected and reported to the Manager of Building Services for documentation.
Manager of Building Services 12/29/2017
3. A review and revision of Protective Services staff acility tour protocol will occur and education on the standards of maintaining stairwell enclosures will be provided to protective services staff, building services team members, and ES community staff.
Director of Facilities 12/29/2017
4. Standard QA facility inspection tours will be reviewed for any stairwell obstruction and findings will be corrected and reports made to the QA.
Director of Facilities 1/5/18

K307 NFPA 101:VERTICAL OPENINGS - ENCLOSURE

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: November 9, 2017
Corrected date: January 5, 2018

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations conducted during the Life Safety Code Survey, it was determined that for one (Reservoir West) of ten exit stair enclosures, and one (Reservoir) of three basements, the facility did not properly maintain fire resistance ratings for vertical openings. Specifically, there were improperly sealed openings in exit stairwells. The findings are: 1. Observations in the presence of the Manager of Building Services on 11/7/17 at approximately 1:35 p.m. revealed several improperly sealed openings between the exit stairwell enclosure leading from the Reservoir basement west end and the adjacent soiled laundry room (chute discharge). The openings extended through the concrete block wall and included two white insulated pipes, a [MEDICATION NAME] pipe, a metal conduit, and a 4-inch unsealed opening on the stairwell side. The annular spaces around the penetrating items were filled only with yellow mineral wool. 2. Observations on 11/9/17 at approximately 10:00 a.m. revealed an unsealed vertical opening between the Reservoir building sixth floor linen alcove across from #615 and the mechanical room penthouse above. The opening was approximately 1-inch wide x 2-feet long and was located around a ventilation duct that extends down through the floor of the mechanical room. The duct was marked as 'St. (NAME)'s 70C-506' and light could be seen around the opening from the sixth-floor corridor below. (10 NYCRR 415.29(a)(2), 711.2(a)(1); 2012 NFPA 101: 19.3.1, 19.3.1.1, 8.6.2)

Plan of Correction: ApprovedDecember 1, 2017

1. The identified penetrations will be sealed utilizing approved processes and rated sealers by Building Services technicians and/or contractors.
Manager of Building Services 12/29/2017
2. Building Services will inspect 100% of the facility for penetrations in vertical shaft ways. Any findings will be reported to the Manager of Building Services for documentation and repair.
Manager of Building Services 12/29/2017
3. Contractor and maintenance protocols will be reviewed, updated and enforced to prevent any future vertical openings. All work performed by contractors or in-house staff requiring the breaching of barrier surfaces will be audited by the Building Services staff and supervisor.
Director of Facilities 12/29/2017
4. Building Services technicians will perform post inspections of any new work for vertical openings. Any findings will be repaired and reports made to the QA as necessary
Director of Facilities As needed