The New Jewish Home, Manhattan
August 26, 2016 Certification Survey

Standard Health Citations

FF09 483.13(c):DEVELOP/IMPLMENT ABUSE/NEGLECT, ETC POLICIES

REGULATION: The facility must develop and implement written policies and procedures that prohibit mistreatment, neglect, and abuse of residents and misappropriation of resident property.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the abuse prohibition policy and procedure was implemented. Specifically, an allegation of abuse was not thoroughly investigated. This was evident for 1 of 1 residents reviewed for Abuse (Resident #201). The finding is: Resident #201 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. On 8/22/16 at 1:16 PM and 8/24/16 at 12:44 PM, the resident's daughter was interviewed at the resident's bedside. She stated that on 7/1/16 or in June, A floating Certified Nursing Assistant (CNA) who cared for the resident on the night shift, snatched the call bell out of her mother's hand when the resident rang it. She further stated that when the call well was snatched, it ricocheted and hit her mother's thumb, creating a bruise in her fingernail. The daughter stated that she learned of the incident because she touched her mother's hand and sheindicated that she was in pain so she asked her what happened.The daughter immediately told the staff on the unit, and a couple of weeks later the Nurse Supervisor told her the CNA had been removed from the floor. She stated that she felt that was strange because the CNA would then be working with other residents. The daughter stated that she informed the Social Worker (SW) about the incident a week later, and was told that she was unaware of the incident. The SW further stated that she was surprised that the nurses had not informed her. The daughter also stated that she did not know if an investigation was completed, but her mother never saw that CNA again. A dark brown mark was observed in the resident's left thumb nail. The daughter and resident both reported that the mark was a bruise sustained when the CNA grabbed the call bell from her. The Grievance Report completed by the Registered Nurse Manager, dated 6/1/16, documented: LPN in charge .informed me that the family member of (Resident) reported to her that the CNA who took care of her mother last night, snatched the call bell from her mother's hand. I then went to (Resident's) room since the daughter was there and I interviewed her again. The daughter told me the same information I got from the nurse. I examined the resident's hand and I did not see any discoloration or swelling and the resident did not complain of pain. The next day, I came at 6:30 am to find out from the night nurse, (nurse name) who the CNA was who took care of (Resident) the previous night. The night nurse told me that it was a floater who took care of (Resident). I told (nurse name) not to assign that floater to (Resident). I made a copy of the assignment sheet so I can investigate. When the daughter came I also informed her that you spoke to the night nurse not to assign that same CNA to her mother .Findings of investigation: assessment done, no evidence of swelling and no discoloration noted. Met the night staff and nurse on duty was not aware of any incident. Resident was interviewed and was not able to provide date, time or name of CNA. Spoke to resident's daughter and reassurance was given that incident like that will not happen again. We could substantiate any allegation of abuse or mistreatment. An undated statement written by the day shift Licensed Practical Nurse documented: The daughter of (Resident) came to me stating that her mother voiced to her the previous night (unsure of time) she rang her call bell, an aid came to the room and snatched the bell from her saying, stop ringing the bell. The daughter was showing me an area on the mother's thumb that was injured but there was no visible injury to me. The nurse manager was called and spoke with daughter about the issue. There were no statements taken from the CNAs that worked with the resident on 5/31/16 or 6/1/16. There was no documented evidence in the medical record that an allegation of abuse was made by the resident's daughter and resident. There was no documented evidence in the medical record that the resident was assessed after the incident or that the incident was investigated. There was no documented evidence in the medical record that the resident was monitored for injury in the days following the incident. On 8/24/16 at 1:12 PM, the day shift Licensed Practical Nurse (LPN) was interviewed and stated the resident's daughter reported to me that the CNA who answered the resident's call bell the night before snatched the cord out of her hand and asked her why she was ringing the bell. She further stated that the daughter reported that the call bell was then placed out of the resident's reach. The LPN stated that she called the Registered Nurse Manager (RNM) and she checked the book to see who was working. She stated that she thinks the RNM spoke to the CNA, a floater, and told the daughter that she would follow-up. The LPN stated that whoever worked that day could not work with the resident. On 8/24/16 at 2:32:43 PM , the RNM was interviewed and stated that she was covering the unit at the time and spoke to the daughter about the concern. She stated the daughter reported the resident said the night shift CNA snatched the call bell from her hand when she rang the bell, and she asked me to find out who the staff member was. She stated that she then came in the next morning at 6:30 AM to find out who the CNA was, and she learned that it was a floating CNA. She told the night nurse not to assign the CNA to the resident again. The RNM stated that she did not see any signs of injury or pain, and the daughter did not report any injuries to her. She stated that she did not document anything in the record or write up an investigation. She also stated that she did not get any information about what happened after the call bell was snatched away from the resident, but putting a call bell out of place and not attending to the resident's needs would be considered abuse. The RNM stated that Allegations of abuse should be written up on an allegation paper, and an investigation with statements from all staff on the unit should be completed. She stated that she did not write it up because she focused on the daughter's complaint that she did not want the CNA assigned to her mother anymore. She stated the investigation is given to the nursing office for the Director of Nursing (DON). The RNM was unable to explain why she did not write up the allegation, and stated that she did not inform the DON. The RNM then returned to the Surveyor at 4:26:57 PM with a Grievance form containing an attached statement from the day shift LPN. She stated that she did not get statements from the CNAs because she never found them. She stated that the fact that she was covering for one day may have stopped her from looking for the CNA. She stated that she thought the nurse would follow-up with the CNA. The RNM stated that she was responsible for completing the investigation and obtaining statements from all staff on duty. She stated if staff are not onsite, the are called so they can come in to do so. When asked when this grievance was completed, the RNM stated that she did not write it today. On 8/24/16 at 3:32 PM, the Director of Social Work (DSW) was interviewed and stated that there is no documentation of the resident's daughter's grievance from the assigned Social Worker in the chart or social work office. She further stated any complaints about staff treatment of [REDACTED]. The DSW stated that if Nursing receives the complaint directly, they may not inform the social worker, but it is good practice to inform the social worker so that they can assess for trauma and make sure the resident feels safe. On 8/24/16 at 4:41 PM, the Director of Nursing (DON) was interviewed and stated that the complaint was completed by the RNM and could not be substantiated. The DON stated that the allegation was vague and there was not way to know when the incident occurred making it difficult to obtain statements from staff. When asked about what she would do in the case of an injury of unknown source, the DON stated that they would interview staff and obtain statements from the previous 3 shifts. She stated that the resident should be assessed and monitored for injury after an allegation of abuse. She stated the RNM did speak to the CNAs, but she did not write up statements for them. The DON stated that if the allegation was substantiated, the CNA would be disciplined. She stated that for an investigation statements should be taken from the staff and attached. The DON added the resident has a history of Dementia and [MEDICAL CONDITION], but she was not trying to say the daughter lied. The facility policy and procedure for Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting of these or other crimes against an elder in our care dated 6/1/12 documented: Inform supervisor of any reported allegations of abuse, neglect, mistreatment, or criminal activity .Removes staff whose care is being investigated from duty immediately pending results of investigation .Initiates investigation of reported situation per policy and procedure Investigation of Incidents and accidents immediately .Alerts department head of suspicion of abuse immediately .Alerts Director of Nursing. The facility policy and procedure for Accident Investigation dated 12/2014 documented: Nurse Manager .Based on a Resident Accident Report, initiates a Accident Investigation form (see attached) and begins to investigate the accident .Within 4 business days, concludes investigation .Documents conclusion of investigation as to the cause of the accident/injury on the Accident Investigation form .Assistant Director of Nursing/Designee .Reviews all Resident Accident Investigation forms to ensure that the investigation has been thorough and that corrective actions taken are appropriate to minimize re-occurrence of accident of injury .Re-evaluates to corroborate determination of Nurse Manager in regard to suspected abuse, neglect, or mistreatment of [REDACTED]. 415.4(b)

Plan of Correction: ApprovedSeptember 16, 2016

I. Plan for Affected Resident
? The investigation of the allegation was completed and it was determined there was no credible evidence of abuse, neglect or mistreatment. (8/25/2016)
? Resident was seen and evaluated by MD/NP on 8/26/2016 and there was no injury noted
? The staff members on the identified unit were all in serviced on the Policy for Abuse Prohibition (8/25/2016)
? The IDCP team met to confirm that comprehensive care plan for the cited resident addressed all identified needs. (9/8/2016)
II. Plan to identify potentially affected residents
? The DNS conducted an audit of all Complaints and Grievances filed within the past six months and determined that there were no other identified residents potentially affected. (9/18/2016)
III. Measures and Systems
? The DNS reviewed the existing policy for Abuse Prohibition and determined that it met all the regulatory requirements for investigating and reporting allegations of abuse. 8/31/2016
? The DNS will educated all appropriate clinical staff on the existing policy (9/16/2016)
The DNS reviewed the existing policy for Investigation of Incidents/Accidents and confirmed that it addressed all elements of a comprehensive and timely investigation including reporting. (9/16/2016)
The DNS/designee will re-educate all appropriate clinical staff on the existing policy (9/30/2016)

IV. Monitoring
On a weekly basis for the next three months and quarterly thereafter, the DNS will audit 100% of all allegations of abuse, neglect and mistreatment to confirm that investigation has been completed. 10/26/2016 and ongoing
? The DNS will present the results of the audits to the QAPI committee meetings on a monthly basis. 10/26/2016 and ongoing
V. Responsible for Compliance
? The DNS will be responsible for maintaining compliance.

FF09 483.25(l):DRUG REGIMEN IS FREE FROM UNNECESSARY DRUGS

REGULATION: Each resident's drug regimen must be free from unnecessary drugs. An unnecessary drug is any drug when used in excessive dose (including duplicate therapy); or for excessive duration; or without adequate monitoring; or without adequate indications for its use; or in the presence of adverse consequences which indicate the dose should be reduced or discontinued; or any combinations of the reasons above. Based on a comprehensive assessment of a resident, the facility must ensure that residents who have not used antipsychotic drugs are not given these drugs unless antipsychotic drug therapy is necessary to treat a specific condition as diagnosed and documented in the clinical record; and residents who use antipsychotic drugs receive gradual dose reductions, and behavioral interventions, unless clinically contraindicated, in an effort to discontinue these drugs.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 16, 2016

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 each resident's drug regimen was free from unnecessary drugs. Specifically, no gradual dose reduction was attempted for a resident without documented behavioral and psychiatric symptoms. This was evident for 1 out of 5 sampled residents reviewed for Unnecessary Medication. (Resident #167) The findings are: Resident # 167 is a [AGE] year old with [DIAGNOSES REDACTED]. The resident was observed on 8/22/16 at approximately 11:00 am in her room sorting through papers. During the observation, the resident was noted to have uncontrollable tongue thrusting movements and lip smacking. Another observation was conducted on 8/23/16 at approximately 9:30 am. The resident was in her room and calmly greeted the SA (State Agency). The resident was observed on 8/24/2016 at approximately 4:00 PM in the main dining room watching television and noted with lip smacking and tongue thrusting movements awaiting dinner. The Quarterly Minimum Data Set (MDS 3.0) dated 5/6/2016 documents that resident is usually understood and understands, cognition is intact. No documented behavior. The mood interview conducted scored 00 (00-27) which indicates no depressive symptoms. The MDS further documented the resident received antianxiety and antidepressant medications during the seven day look back period. The Psychiatry consult dated 11/10/15 documented: the patient has been stable without recent behavioral issues. The staff indicates the patient has been stable without recent behavioral issues. Plan/recommendations: 1. continue current [MEDICAL CONDITION] medications 2. follow up 12-16 weeks and PRN 3. GDR: NO, not indicated due to risk of relapse. Physician orders [REDACTED]. Medication Administration Records document the resident received [MEDICATION NAME] 0.5 mg 1/2 tablet (0.25 mg) at 9:00 am and 5:00pm daily from 11/19/2015 to present. Psychiatry consult dated 2/1/2016 documented: On interview patient was resting in bed calm, impoverished. The patient did not indicate current psychiatric complaints. The chart does not indicate acute interval changes in mood, behavior or activity. The staff indicates the patient has been stable without recent behavioral issues. The patient did not appear in distress or exhibit signs or symptoms of agitation. The patient has indication for her current [MEDICAL CONDITION] regimen which she appears to be benefiting from without adverse side effects would continue current [MEDICAL CONDITION] regimen plan/ recommendations document 1. continue current [MEDICAL CONDITION] regimen 2. follow up 12-16 weeks or PRN 3. GDR: No, not indicated due to risk of relapse. The Psychiatry Consult dated 5/18/16 documented: Upon interview, the patient was resting in room, in bed. The patient was alert to person only and somewhat impoverished. The patient did not have psychiatric complaints, the patient did not appear in distress. The staff indicates the patient has been stable without recent behavioral issues. Plan/recommendations: 1. Would increase [MEDICATION NAME] to 45 mg 2. Continue other [MEDICAL CONDITION] regimen 3. Follow up 8-12 weeks or PRN 4. GDR: No, not indicated. The Psychiatric consult dated 8/1/2016 documented: patient was calm and receptive to interaction, did not have psychiatric complaints, did not appear in distress or exhibit signs or symptoms of agitation. Psych medications: [REDACTED]. Recommendation: continue current [MEDICAL CONDITION] regimen, follow up 8-12 weeks, Gradual dose reduction (GDR) not indicated as there are no clinical benefits from GDR. Physicician progress note dated 7/28/2016 documented the resident has no new complaints, staff has no issues, no change in behavior, mood or activity, po intake and weight has been stable, being followed by psych last seen on 5/18/2016- increased [MEDICATION NAME] to 45 mg at bedtime and continue [MEDICATION NAME] and [MEDICATION NAME]. Psych assessment document calm, interactive, repetitive. Assessment /Plan: Dementia/depression/anxiety- stable, continue [MEDICATION NAME] ([MEDICATION NAME])[MEDICATION NAME] and [MEDICATION NAME] as per psych. Progress notes from 8/2015-8/2016 were reviewed. There was no documented evidence that the resident exhibited behavioral symptoms. Review of the Standards Of Care care plan for [MEDICAL CONDITION] Drug was reviewed. Behavior symptoms was not checked. The care plan interventions included: Review medications at least monthly for dose appropriateness and potential for dose reduction or discontinuance; identify and utilize non-pharmalogic behavioral interventions that may decrease the need for medication per the Resident Care Summary and monitor for and manage any side effects of medications. There was no documented evidence that non-pharmalogical behavioral interventions had been attempted from 11/2015 through 8/2016. There was also no documented evidence that gradual dose reduction was attempted in the absence of behavioral symptoms from 11/2015 to 8/2016. An interview was conducted with a Certified Nursing Assistant (CNA) on 8/24/2016 who stated that there was no non-pharmalogical interventions that she was aware of and that the resident had not exhibited behaviors. An interview was conducted on 8/24/2016 at approximately 4:30 with the Licenced Practical Nurse (LPN) who stated that the resident can be impatient at times but had not displayed any behavioral outbursts and was not a danger to herself or others. An interview was conducted with the RN/Unit Manager on 8/24/16 at 4:42 PM who stated that she is responsible for updating the care plans and the resident care summaries. She further stated that behavior symptoms was not indicated on the Record of Care Plan Activities since the resident had not displayed any behaviors. On 8/26/16 at approximately 12:30 an phone interview was conducted with the Psychiatrist who stated that the resident has no adverse side effects from the medication, and has been treated long term with [MEDICATION NAME]. In response to the absence of psychiatric or behavioral symptoms, the Psychiatrist stated sounds like she can probably do without it I will look at it during my next visit. On 8/25/2016 at approximately 3:15pm an interview was conducted with the Medical director who stated that the resident medications are reviewed every sixty days by the unit Physician for continued appropriateness of antipsychotic medication. She further stated that [MEDICATION NAME] was reduced 11/2015 and since then there has been concerns related to dependence and did not elaborate as to why a gradual dose reduction was not attempted. She further stated that the resident has an obsession with oral care, but no other documented behavioral/psychiatric symptoms or evidence of being a danger to self or others. During the review the physician reviews the medical record for behaviors and speaks to the nursing staff to identify behaviors. 415.12(1)(1)

Plan of Correction: ApprovedSeptember 23, 2016

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** 1. Plan for Affected Resident
. The resident was evaluated by the medical team and psychiatrist with no recommendation to change the current medication regimen She exhibited mild anxiety on exam has no recent falls and it was determined that she would be at high risk of withdrawal should the dose of [MEDICATION NAME] be discontinued therefore gradual dose reduction is medically contraindicated for this resident. (9/16/2016)
The IDCP team met to confirm that the that the comprehensive care plan for the cited resident addressed all identified needs. (9/16/16)
II. Plan for Potentially Affected Residents
. The medical director and the director of pharmacy conducted a chart review and an interdisciplinary team review for all of the 48 residents currently receiving anxiolytic medication. A gradual dose reduction will commence for those residents identified as potentially at risk. 9/18/2016.
III. Measures and Systems
The Director of Pharmacy has reviewed the facility's policy for Medication Management Review and revised it to include a review of each nursing facility resident's medication regimen at least once a month to identify irregularities and clinical significant risks and/or adverse consequences resulting from, or associated with medications. It may be necessary for a pharmacist to conduct the medication regimen review more frequently depending on the residents condition, with the goal of promoting positive outcomes and minimizing adverse consequences associated with medication. (9/23/2016)
The Director of Pharmacy will educate all appropriate clinical staff on the revised policy (9/30/2016).
The medical director and director of pharmacy reviewed the facility?s existing policy for antipsychotic medication use and confirmed that it meets all of the regulatory requirements for gradual dose reduction. (9/16/2016)
The Director of Nursing has reviewed the facility's existing policy for Behavior Management and Documentation and revised the requirement for assessment and documentation to be at a minimum weekly. (9/22/2016)
. The medical director will re-inservice all appropriate clinical staff on the existing policy for antipsychotic medication. (9/30/2016)
The Director of Nursing/designee will inservice all appropriate nursing staff on the revised policy for behavior management and documentation (9/30/2016)
IV. Monitoring
On a monthly basis for the next three months the medical director/designee will audit 10% of residents receiving antipsychotic medication to confirm compliance with the facility?s policy got gradual dose reduction. 10/26/2016 and ongoing.
On a monthly basis for the next three months the nursing director/designee will audit 10% of residents receiving antipsychotic medication to confirm compliance with the revised policy for assessment and documentation of behaviiors (10/26/2016 and ongoing)
. The results of these audits will be presented at the facility?s Pharmacy & Therapeutic Committee 10/26/2016 and ongoing
. The P&T Committee will report recommendations for ongoing auditing to the QAPI committee
10/26/2016 and ongoing

V. Responsible for compliance
. The Medical Director will be responsible for maintaining compliance.

FF09 483.65:INFECTION CONTROL, PREVENT SPREAD, LINENS

REGULATION: The facility must establish and maintain an Infection Control Program designed to provide a safe, sanitary and comfortable environment and to help prevent the development and transmission of disease and infection. (a) Infection Control Program The facility must establish an Infection Control Program under which it - (1) Investigates, controls, and prevents infections in the facility; (2) Decides what procedures, such as isolation, should be applied to an individual resident; and (3) Maintains a record of incidents and corrective actions related to infections. (b) Preventing Spread of Infection (1) When the Infection Control Program determines that a resident needs isolation to prevent the spread of infection, the facility must isolate the resident. (2) 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. (3) The facility must require staff to wash their hands after each direct resident contact for which hand washing is indicated by accepted professional practice. (c) Linens Personnel must handle, store, process and transport linens so as to prevent the spread of infection.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 16, 2016

Citation Details

Based on observation and staff interview, the facility did not ensure that infection control practices were maintained. Specifically, 1) the LPN turned off the faucet after hand hygiene with her bare hands; 2) the LPN did not remove her gloves after removing the soiled dressing to the resident's stage 4 sacral pressure ulcer and proceeded with the remainder of the wound care. This was evident for 1 of 3 residents reviewed for Pressure Ulcer care and Infection Control Practices. (Resident #201). The finding is: On 8/25/2016 at 11:30 a.m., a wound care observation was conducted and the following was observed: 1) After preparing wound care supplies on the resident's overbed table, the LPN (Licensed Practical Nurse) opened the bathroom door with her gloved hands, removed the gloves and washed her hands. The LPN then turned off the faucet with her bare hands. The LPN did not use a clean paper towel to turn off the faucet after washing her hands. 2) She donned clean gloves and removed the soiled dressing from the resident's stage 4 sacral pressure ulcer, and cleansed the wound with normal saline. The LPN proceeded with the application of Calcium Alginate and a dry dressing. The LPN did not remove her gloves and wash her hands after removing the soiled dressing and proceeding with the remainder of the wound care. An interview was conducted with the LPN (who performed the wound care) on 8/25/2016 at 11:45 a.m. The LPN stated that she thought she had washed her hands and changed her gloves and was unable to explain why she had not done so. The LPN further stated that she receives in-service training on hand hygiene and wound care every year and could not recall when was the last time she had received training. The Registered Nurse Manager was interviewed on 8/26/16 at 12:15 p.m., and stated that she tries to conduct observations of the nurse performing wound care to ensure that the handwashing technique is within accepted standards and at the appropriate times. She also stated that the nurse was supposed to remove her gloves, wash her hands, and don clean gloves after cleaning the wound before applying the treatment and dressing. She further stated that in-service training is provided on both hand-washing and wound care every six months. On 8/26/16 at 12:25 p.m., an interview was conducted with the Assistant Director of Nursing who stated that the Nurse Managers are responsible for ensuring that appropriate wound care is done. She also stated that the expectation is that hand hygiene is performed when gloves are changed and when contact is made with the wound, preferably hand-washing and at the beginning and end of wound care. She further stated that in-service on hand-washing is done quarterly and as needed. 415.19(a)(1-3)

Plan of Correction: ApprovedSeptember 15, 2016

I. Plan for Affected Resident
? The ADNS re-in serviced the LPN involved in the resident?s care on the proper hand hygiene for wound care. 8/24/16
? The LPN preformed a return demonstration of the proper technique for hand hygiene while performing wound care 8/24/2016
? The IDCP team met to confirm that the comprehensive care plan for the cited resident addressed all identified needs. 8/26/2016
II. Plan to identify potentially affected
? The Assistant Director of Nursing /Nursing Supervisors observed all licensed nursing on the performance of hand hygiene during wound care and determined that there were no other potentially affected residents
? Completion date: 9/18/2016
III. Measures and Systems
? The DNS reviewed the existing policy for Hand Hygiene and Wound Care and determined it meets the requirements for infection control as outlined by the CDC (8/24/16)
?
? The ADNS/Nursing Supervisors will re- educate all appropriate licensed nurses on the existing policies hand hygiene and wound care. (9/28/2016)
IV. Plan for Follow-Up/Monitoring
? On a monthly basis, for the next three months , the Assistant DNS/designee will observe 10% of all licensed nurses in the performance of hand hygiene as it relates to wound care (Date 10/26/2016 and ongoing)
? The results of the audits will be reported to the Director of Nursing (10/26/2016 and ongoing)
? The DNS will present the reports to the QAPI committee meetings on a monthly basis. 10/26/2016 and ongoing
? Based on the results of the audits the QAPI committee will recommend frequency of ongoing auditing 10/26/2016
V. Responsible for Compliance
? The DNS will be responsible for maintaining compliance.

FF09 483.13(c)(1)(ii)-(iii), (c)(2) - (4):INVESTIGATE/REPORT ALLEGATIONS/INDIVIDUALS

REGULATION: The facility must not employ individuals who have been found guilty of abusing, neglecting, or mistreating residents by a court of law; or have had a finding entered into the State nurse aide registry concerning abuse, neglect, mistreatment of residents or misappropriation of their property; and report any knowledge it has of actions by a court of law against an employee, which would indicate unfitness for service as a nurse aide or other facility staff to the State nurse aide registry or licensing authorities. The facility must ensure that all alleged violations involving mistreatment, neglect, or abuse, including injuries of unknown source and misappropriation of resident property are reported immediately to the administrator of the facility and to other officials in accordance with State law through established procedures (including to the State survey and certification agency). The facility must have evidence that all alleged violations are thoroughly investigated, and must prevent further potential abuse while the investigation is in progress. The results of all investigations must be reported to the administrator or his designated representative and to other officials in accordance with State law (including to the State survey and certification agency) within 5 working days of the incident, and if the alleged violation is verified appropriate corrective action must be taken.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 16, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, record review, and interview, the facility did not ensure that the an allegation of abuse/neglect was thoroughly investigated. This was evident for 1 of 1 resident reviewed for Abuse (Resident #201). The finding is: Resident #201 is an [AGE] year-old with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. On 8/22/16 at 1:16 PM and 8/24/16 at 12:44 PM, the resident's daughter was interviewed at the resident's bedside. She stated that on 7/1/16 or in June, A floating Certified Nursing Assistant (CNA) who cared for the resident on the night shift, snatched the call bell out of her mother's hand when the resident rang it. She further stated that when the call well was snatched, it ricocheted and hit her mother's thumb, creating a bruise in her fingernail. The daughter stated that she learned of the incident because she touched her mother's hand and sheindicated that she was in pain so she asked her what happened.The daughter immediately told the staff on the unit, and a couple of weeks later the Nurse Supervisor told her the CNA had been removed from the floor. She stated that she felt that was strange because the CNA would then be working with other residents. The daughter stated that she informed the Social Worker (SW) about the incident a week later, and was told that she was unaware of the incident. The SW further stated that she was surprised that the nurses had not informed her. The daughter also stated that she did not know if an investigation was completed, but her mother never saw that CNA again. A dark brown mark was observed in the resident's left thumb nail. The daughter and resident both reported that the mark was a bruise sustained when the CNA grabbed the call bell from her. The Grievance Report completed by the Registered Nurse Manager, dated 6/1/16, documented: LPN in charge .informed me that the family member of (Resident) reported to her that the CNA who took care of her mother last night, snatched the call bell from her mother's hand. I then went to (Resident's) room since the daughter was there and I interviewed her again. The daughter told me the same information I got from the nurse. I examined the resident's hand and I did not see any discoloration or swelling and the resident did not complain of pain. The next day, I came at 6:30 am to find out from the night nurse, (nurse name) who the CNA was who took care of (Resident) the previous night. The night nurse told me that it was a floater who took care of (Resident). I told (nurse name) not to assign that floater to (Resident). I made a copy of the assignment sheet so I can investigate. When the daughter came I also informed her that you spoke to the night nurse not to assign that same CNA to her mother .Findings of investigation: assessment done, no evidence of swelling and no discoloration noted. Met the night staff and nurse on duty was not aware of any incident. Resident was interviewed and was not able to provide date, time or name of CNA. Spoke to resident's daughter and reassurance was given that incident like that will not happen again. We could not substantiate any allegation of abuse or mistreatment. An undated statement written by the day shift Licensed Practical Nurse documented: The daughter of (Resident) came to me stating that her mother voiced to her the previous night (unsure of time) she rang her call bell, an aide came to the room and snatched the bell from her saying, stop ringing the bell. The daughter was showing me an area on the mother's thumb that was injured but there was no visible injury to me. The nurse manager was called and spoke with daughter about the issue. There were no statements taken from the CNAs that worked with the resident on 5/31/16 or 6/1/16. There was no documented evidence in the medical record that an allegation of abuse was made by the resident's daughter and resident. There was no documented evidence in the medical record that the resident was assessed after the incident or that the incident was investigated. There was no documented evidence in the medical record that the resident was monitored for injury in the days following the incident. On 8/24/16 at 1:12 PM, the day shift Licensed Practical Nurse (LPN) was interviewed and stated the resident's daughter reported to me that the CNA who answered the resident's call bell the night before snatched the cord out of her hand and asked her why she was ringing the bell. She further stated that the daughter reported that the call bell was then placed out of the resident's reach. The LPN stated that she called the Registered Nurse Manager (RNM) and she checked the book to see who was working. She stated that she thinks the RNM spoke to the CNA, a floater, and told the daughter that she would follow-up. The LPN stated that whoever worked that day could not work with the resident. On 8/24/16 at 2:32:43 PM , the RNM was interviewed and stated that she was covering the unit at the time and spoke to the daughter about the concern. She stated the daughter reported the resident said the night shift CNA snatched the call bell from her hand when she rang the bell, and she asked me to find out who the staff member was. She stated that she then came in the next morning at 6:30 AM to find out who the CNA was, and she learned that it was a floating CNA. She told the night nurse not to assign the CNA to the resident again. The RNM stated that she did not see any signs of injury or pain, and the daughter did not report any injuries to her. She stated that she did not document anything in the record or write up an investigation. She also stated that she did not get any information about what happened after the call bell was snatched away from the resident, but putting a call bell out of place and not attending to the resident's needs would be considered abuse. The RNM stated that Allegations of abuse should be written up on an allegation paper, and an investigation with statements from all staff on the unit should be completed. She stated that she did not write it up because she focused on the daughter's complaint that she did not want the CNA assigned to her mother anymore. She stated the investigation is given to the nursing office for the Director of Nursing (DON). The RNM was unable to explain why she did not write up the allegation, and stated that she did not inform the DON. The RNM then returned to the Surveyor at 4:26:57 PM with a Grievance form containing an attached statement from the day shift LPN. She stated that she did not get statements from the CNAs because she never found them. She stated that the fact that she was covering for one day may have stopped her from looking for the CNA. She stated that she thought the nurse would follow-up with the CNA. The RNM stated that she was responsible for completing the investigation and obtaining statements from all staff on duty. She stated if staff are not onsite, the are called so they can come in to do so. When asked when this grievance was completed, the RNM stated that she did not write it today. On 8/24/16 at 3:32 PM, the Director of Social Work (DSW) was interviewed and stated that there is no documentation of the resident's daughter's grievance from the assigned Social Worker in the chart or social work office. She further stated any complaints about staff treatment of [REDACTED]. The DSW stated that if Nursing receives the complaint directly, they may not inform the social worker, but it is good practice to inform the social worker so that they can assess for trauma and make sure the resident feels safe. On 8/24/16 at 4:41 PM, the Director of Nursing (DON) was interviewed and stated that the complaint was completed by the RNM and could not be substantiated. The DON stated that the allegation was vague and there was not way to know when the incident occurred making it difficult to obtain statements from staff. When asked about what she would do in the case of an injury of unknown source, the DON stated that they would interview staff and obtain statements from the previous 3 shifts. She stated that the resident should be assessed and monitored for injury after an allegation of abuse. She stated the RNM did speak to the CNAs, but she did not write up statements for them. The DON stated that if the allegation was substantiated, the CNA would be disciplined. She stated that for an investigation statements should be taken from the staff and attached. The DON added the resident has a history of Dementia and [MEDICAL CONDITION], but she was not trying to say the daughter lied. The facility policy and procedure for Abuse/Neglect/Mistreatment-Prevention, Assessment & Reporting of these or other crimes against an elder in our care dated 6/1/12 documented: Inform supervisor of any reported allegations of abuse, neglect, mistreatment, or criminal activity .Removes staff whose care is being investigated from duty immediately pending results of investigation .Initiates investigation of reported situation per policy and procedure Investigation of Incidents and accidents immediately .Alerts department head of suspicion of abuse immediately .Alerts Director of Nursing. The facility policy and procedure for Accident Investigation dated 12/2014 documented: Nurse Manager .Based on a Resident Accident Report, initiates a Accident Investigation form (see attached) and begins to investigate the accident .Within 4 business days, concludes investigation .Documents conclusion of investigation as to the cause of the accident/injury on the Accident Investigation form .Assistant Director of Nursing/Designee .Reviews all Resident Accident Investigation forms to ensure that the investigation has been thorough and that corrective actions taken are appropriate to minimize re-occurrence of accident of injury .Re-evaluates to corroborate determination of Nurse Manager in regard to suspected abuse, neglect, or mistreatment of [REDACTED]. 415.4(b)(1)(ii)

Plan of Correction: ApprovedSeptember 16, 2016

I. Plan for Affected Resident
? The investigation of the allegation was completed and it was determined there was no credible evidence of abuse, neglect or mistreatment. (8/25/2016)
? Resident was seen and evaluated by MD/NP on 8/26/2016 and there was no injury noted
? The staff members on the identified unit were all in serviced on the Policy for Abuse Prohibition (8/25/2016)
? The IDCP team met to confirm that comprehensive care plan for the cited resident addressed all identified needs. (9/8/2016)
II. Plan to identify potentially affected residents
? The DNS conducted an audit of all Complaints and Grievances filed within the past six months and determined that there were no other potentially affected residents. (9/18/2016)
III. Measures and Systems
? The DNS reviewed the existing policy for Abuse Prohibition and determined that it met all the regulatory requirements for investigating and reporting allegations of abuse. 8/31/2016
? The DNS educated all appropriate clinical staff on the existing policy (8/31/16)
The DNS reviewed the existing policy for Investigation of Incidents/Accidents and confirmed that it addressed all elements of a comprehensive and timely investigation including reporting. (9/16/2016)
The DNS/designee will re-educate all appropriate clinical staff on the existing policy (9/30/2016)
IV. Monitoring
On a weekly basis for the next three months and quarterly thereafter, the DNS will audit 100% of all allegations of abuse, neglect and mistreatment to confirm that investigation has been completed. 10/26/2016 and ongoing
? The DNS will present the results of the audits to the QAPI committee meetings on a monthly basis. 10/26/2016 and ongoing
V. Responsible for Compliance
? The DNS will be responsible for maintaining compliance.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Corridors are separated from use areas by walls constructed with at least 1/2 hour fire resistance rating. In fully sprinklered smoke compartments, partitions are only required to resist the passage of smoke. In non-sprinklered buildings, walls extend to the underside of the floor or roof deck above the ceiling. (Corridor walls may terminate at the underside of ceilings where specifically permitted by Code. Charting and clerical stations, waiting areas, dining rooms, and activity spaces may be open to corridor under certain conditions specified in the Code. Gift shops may be separated from corridors by non-fire rated walls if the gift shop is fully sprinklered.) 19.3.6.1, 19.3.6.2, 19.3.6.4, 19.3.6.5

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 26, 2016
Corrected date: October 16, 2016

Citation Details

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. 42 CFR 483.70 (a) K 017 S/S=B Television Rooms/Dining rooms on patient floors in the Sutro Pavilion are not separated from the Corridor. NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 4, 2016

This requirement has been previously waived and this facility isrequesting continuation of the waiver. The conditions under which the waiver was granted have not changed.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit access is arranged so that exits are readily accessible at all times in accordance with section 7.1. 19.2.1

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 26, 2016
Corrected date: October 16, 2016

Citation Details

The following requirement has been waived. Repeat waivers are granted based on previous justifications by the owner, previous NYSDOH and USDHHS reviews and certification that the condition under which the waivers have been granted have not changed. Please indicate if the facility wishes the waiver to be continued or provide a plan of correction. 42 CFR 483.70 (a) K 038 S/S=B Where accumulation of snow or ice is likely because of the climate, the exterior exit access shall be protected by a roof. The access to the alternate exit on the 8th floor of the(NAME)Building is via an unprotected roof area. 5-5.3.8 NYCRR 711.2 (a)(1)

Plan of Correction: ApprovedNovember 4, 2016

This requirement has been previously waived and this facility is requesting continuation of the waiver. The conditions under which the waiver was granted have not changed. 8/29/16

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Doors protecting corridor openings in other than required enclosures of vertical openings, exits, or hazardous areas shall be substantial doors, such as those constructed of 13/4 inch solid-bonded core wood, or capable of resisting fire for at least 20 minutes. Clearance between bottom of door and floor covering is not exceeding 1 inch. Doors in fully sprinklered smoke compartments are only required to resist the passage of smoke. There is no impediment to the closing of the doors. Hold open devices that release when the door is pushed or pulled are permitted. Doors shall be provided with a means suitable for keeping the door closed. 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 8.2.3.2.1. Roller latches are prohibited by CMS regulations in all health care facilities. 19.3.6.3

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 22, 2016

Citation Details

NFPA 101 2000 LIFE SAFETY CODE STANDARD 19.3.6.3 Corridor Doors 19.3.6.3.1 Doors protecting corridor openings in other than required enclosures of vertical openings, exits or hazardous areas shall be substantial doors, such as those constructed of 1 3/4 inch thick solid -bonded core wood or of construction that resists fire for not less than 20 minutes and shall be constructed to resist the passage of smoke 19.3.6.4. Transfer grilles. Transfer grilles, regardless of whether they are protected by fusible link operated dampers, shall not be used on these walls or doors. Exception: Doors to toilet rooms, bathrooms, shower rooms, sink closet and similar auxiliary spaces that do not contain flammable or combustible materials shall be permitted to have ventilating louvers or to be undercut. Based on observation and interview it was determined that the facility did not ensure that doors protecting the corridor at the facility were smoke resistant as evidenced by the door to the security office located on the ground floor of the(NAME)building that was equipped with transfer grilles. The findings are: On 08/22/16 and 08/23/16 during the life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that the door to the security office located on the ground floor of the(NAME)building was equipped with transfer grilles. NFPA 101 Section 19.3.6.4 prohibits the use of transfer grilles on corridor doors that do not meet the exceptions in this section. In an interview on 08/22/16, the director of environmental services of the facility stated that the issue will be brought to the attention to the facility's director of plant operations. 2000 NFPA 101- 19.3.6.3, 19.3.6.4 711.2(a) (1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The louver in the door to the Security supervisor?s
office located on the Friedman Ground floor was
removed and the door upgraded to meet the required
standard. 9/15/16
II. Plan to Identify other potential affected areas
The Director of Facility has reviewed all doors within the facility to confirm that all remaining doors meet the cited standard. Doors that do not meet the cited standard will be replaced.
III. Measures and Systems
The current survey of all doors shall be update and each time a door is scheduled to be changed or upgraded it is evaluated prior to installation confirm it is appropriate under the most current
NFPA Life safety.
IV. Monitoring
The Associate Director of Facilities Management will review the specifications for any new or replacement door that is to installed prior to installation. The Life safety shall be used to determine the required regulatory requirements before purchase.
V. Responsibility
The Director of Facilities management shall be responsible for reviewing the findings for all door purchases prior to approval of purchase orders.
All doors purchases and installation review shall be archived for reference.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

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

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 21, 2016

Citation Details

Based on observation and interview it was determined that the facility did not ensure that doors protecting hazardous areas were made self-closing and maintained to self-close as evidenced by the doors to(NAME)building 3rd Fl storage room, the sprinkler vendor/construction office on the ground floor of the Sutro building, and(NAME)building maintenance storage room, fan room, linen chute discharge room, IT server room and electrical meter room that did not self-close when tested . The findings are: On 08/22/16 and 08/23/16 during the annual life safety recertification survey between 9:30 am and 3:30 pm, it was observed that the door to the(NAME)building's 3rd Floor storage room did not self-close when tested . It was also observed that the sprinkler vendor/construction office located on the ground floor of facility's Sutro building was used to store construction material and numerous blueprint rolls and the door to the corridor was not made self-closing. In additon, it was also noted that a number of doors to hazardous areas in facility's(NAME)building were not made self-closing or maintained to self-close. Examples include but are not limited to: - The corridor door to the maintenance storage room did not self-close and positively latch when tested . -The corridor door to the mechanical-fan room was not made self-closing. - The door to the linen chute discharge room did not self close when tested . - The doors to the IT server room and electrical meter room that were not made self closing. In an interview on 08/23/16 with the director of environmental services of the facility (DES), she stated that she will bring these issues to the attention of the facility's director of plant operations. 2000 NFPA 101 19.3.2.1 711.2(a)(1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The doors(NAME)storage room, the(NAME)
Maintenance storage room,(NAME)fan room,
Friedman line chute discharge room and IT server
Room and electrical room were serviced and made
self closing and positively latching. The Sutro sprinkler construction office has had the necessary hardware installed to make it self closing and positively latching. 9/30/2016
II. Plan to identify other potentially affected areas.
All areas of the facility have a complete evaluation with regards to the maintenance of the existing doors which are required to be self closing and positively latching. A second evaluation was made of all existing doors to
determine if they are required to be self closing and positively latching. Those not meeting the requirement are being fitted with appropriate hardware.
III. Measures and Systems
E(NAME) rounds that occur on resident units will be expanded to the basement and nonresident high use areas on a weekly basis. This action will help identify the areas that require smaller maintenance cycles or upgrade to more durable equipment.
Those areas identified will have their maintenance cycles shortened or the equipment upgraded.
IV. Monitoring
The associate Director of Facilities Management, the Security supervisor and Environmental Services Director, as a team, shall conduct and document
the inspections, determine the need for maintenance cycle changes and recomend equipment upgrades and or replacement.
V. Responsibility
The Director of Facilities Management shall be responsible for reviewing the Groups recommendations and presenting them to the Environment of Care Committee for their review. He will also provide the support and identify funding
for the required upgrades.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture will not leave the area in darkness. Lighting system shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8, 7.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 7, 2016

Citation Details

19.2.8 Illumination of Means of Egress. Illumination of means of egress, including exit discharge, is arranged so that failure of any single lighting fixture will not leave the area in darkness. Lighting system shall be either continuously in operation or capable of automatic operation without manual intervention. 18.2.8, 19.2.8, 7.8 Based on observation and interview, the facility did not provide emergency exit lighting at the 5th floor G stairwell of the Friedman building. The Finding is: During the life safety code recertification survey conducted on (MONTH) 23, (YEAR), at approximately 11:00 A.M, it was observed that there was no lighting inside the 5th floor G stairwell of the Friedman building. On (MONTH) 23, (YEAR) at approximately 11:15 A.M in an interview with the Maintenance Director, he stated that this concern will be corrected immediately. 2000 NFPA 101: 19.2.8, 7.8.1.4 10 NYCRR 711.2(a)(1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The stairwell light fixture on the(NAME)5th floorStair well G was serviced and the bulb replaced. 8/28/16
II. Plan to identify other potentially affected areas
All other stair cases and means of egress were inspected to Confirm all areas were effectively lit and the loss of one fixture would not leave the staircase without light.
III. Measures and Systems
Current program of quarterly inspections by the Engineering department will be changed to monthly. The Security department personnel will monitor
stairwell and egress lighting during their normal security rounds. All deficiencies shall be logged and reported to the Security manager for action.
IV. Monitoring
During weekly E(NAME) rounds the inspection team shall
check Egress lighting adjacent to each floor. The Associate Director of Engineering shall review the new month service logs to conform compliance within the department.
V. Responsibility
The Director of Facilities Management shall quarterly review all service logs to confirm all actions are implemented. Outcome
of the review shall be reported to the E(NAME) committee.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Exit enclosures (such as stairways) are enclosed with construction having a fire resistance rating of at least one hour, are arranged to provide a continuous path of escape, and provide protection against fire or smoke from other parts of the building. 7.1.3.2, 8.2.5.2, 8.2.5.4, 19.3.1.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 22, 2016

Citation Details

Based on observation, it was determined that the facility did not ensure that exit stairways were enclosed with fire resistance rating construction of at least one hour as per 7.1.3.2. Reference is made to the ventilation openings (louvers) in exit stairway H in the Frank building that were sealed with plywood of unknown fire resistance rating. The findings include: On (MONTH) 22 and 23, (YEAR) at 10:00 AM to 3:00 PM, it was observed that the facility's exit stairway H serving the Frank building had ventilation grilles at the roof level. The grilles were noted sealed with plywood of unknown fire resistance rating. Openings through the exit stair enclosures must be sealed with material having the same fire resistance rating as the construction of the stair enclosure as per 7.1.3.2.1. On (MONTH) 23, (YEAR) at approximately 12:00 PM, the facility's director of engineering stated that the ventilation grilles in stair H enclosure in the Frank building will be sealed with material having the required fire resistance rating as per 7.1.3.2.1. 711.2 (a)(1) 2000 NFPA 101

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The plywood material and grills located in the frank Building Stairwell H
have been removed and replaced with appropriate material. The stair case has been restored to it appropriate rating. 9/23/2016
II. Plan to identify other potential areas.
An inspection of all fire stair cases within the facilities was conducted by the Director of Facilities Management. The stair cases were free from other inappropriate materials.
III. Measure and Systems
As part of the E(NAME) safety rounds program the fire staircases will beaded as a quarterly Inspection area. Outcome of the inspections will be added to the E(NAME) rounds reports.
IV. Monitoring
The outcome of the E(NAME) safety rounds shall be reported to the Environment of Care Committee for comment, action and recommendation.
V. Responsibility
The Director of Facilities management shall review the E(NAME) safety reports and submit the reports to the E(NAME) committee for review. He shall be responsible for implementing corrective
actions as necessary.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Smoking regulations are adopted and include no less than the following provisions: (1) Smoking is 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 is posted with signs that read NO SMOKING or with the international symbol for no smoking. (2) Smoking by patients classified as not responsible is prohibited, except when under direct supervision. (3) Ashtrays of noncombustible material and safe design are provided in all areas where smoking is permitted. (4) Metal containers with self-closing cover devices into which ashtrays can be emptied are readily available to all areas where smoking is permitted. 19.7.4

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 23, 2016

Citation Details

2000 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 compartment 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. Exception: 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. (2) Smoking by patients classified as not responsible shall be prohibited. Exception: The requirement of 19.7.4(2) shall not apply where the patient is under direct supervision. (3) Ashtrays of noncombustible material and safe design shall be provided in all areas where smoking is permitted. (4) 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 interview it was determined that the facility did not ensure that residents' smoking room located on the ground floor of the Sutro building was provided with the required metal container with self-closing cover devices into which ashtrays can be emptied. The findings are: On 08/22/16 and 08/23/16 during the life safety recertification survey between 9:30 am and 3:30 pm, it was observed that the facility's smoking room was located on the ground floor of the Sutro building. It was also observed that the smoking room was equipped with a free standing type ashtray and lacked the required metal container with self-closing cover devices into which ashtrays can be emptied. In an interview on 08/23/16 with the director of plant operations, he stated that the room will be provided with the required metal container as soon as possible. 2000 NFPA 101 19.7.4 711.2(a)(1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for cited area
The resident smoking room located on the ground floor of the Sutro Building has been equipped
with a metal container with self closing cover so ash trays may be dumped as required. 9-23-16
II. Plan to identify other potentially affected areas.
The Sutro ground floor resident smoking room is the
only area in which resident smoking is allowed.
III. Measures and Systems
The New Jewish Home is a smoke free facility with only one grandfathered smoker left in the facility.
The smoking room is locked and access is controlled by the Security department so the remaining resident can be monitored on a continuous basis.
The Security Department will control and monitor the
smoking room and the Environmental Services Department will empty the ash container on a daily basis.
IV. Monitoring
The smoking room will be added to the weekly Environment of Care rounding schedule to ensure that the proper container is in place
V. Responsibility
The Director of Environmental services will be responsibleFor maintaining the smoking room and disposal of smoking materials as necessary.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Heating, ventilating, and air conditioning comply with the provisions of section 9.2 and are installed in accordance with the manufacturer's specifications. 19.5.2.1, 9.2, NFPA 90A, 19.5.2.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: October 16, 2016

Citation Details

Section 3-3.1.1, NFPA 90 A - Standard for the Installation of Air Conditioning and Ventilating Systems, states that approved fire dampers shall be provided where air ducts penetrate or terminate at openings in walls or partitions required to have a fire resistance rating of 2 hours or more. This Standard is not met as evidenced by: Based on observation and staff interview, it was determined that the facility did not ensure that approved fire dampers were provided where ventilation ducts penetrate the 2 hour fire resistance rated walls. Reference is made to the ventilation duct penetrating the central storage room enclosure wall in the basement of Sutro building that lacked the required fire dampers as per NFPA 90 A. The findings include: On (MONTH) 22, (YEAR) at 10:00 AM to 3:00 PM, it was observed that multiple HVAC ducts penetrated the centralized storage room walls ( 2 hour enclosure walls ) in the vicinity of exit stair B in the basement of Sutro building. The presence of fire dampers at the wall penetrations could not be confirmed by the surveyor or the facility's director of engineering. On (MONTH) 23, (YEAR) at approximately 12:15 AM, the facility's director of engineering stated that the HVAC company will be contacted to install approved fire dampers at the storage room area walls that were penetrated by the ventilation ducts. 711.2 (a)(1) 2000 NFPA 101 1999 NFPA 90 A

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The duct work at the Sutro central storage room that passes through rated walls has been inspected and dampers are being fitted to ensure these ducts comply with the code. 10/22/16
II. Plan to identify other affected areas
A review of the duct work at all rated walls of the facilities buildings Is being conducted by the Director and Associate Director of Facilities
to confirm that other systems and duct work comply with the standard.
III. Measures and Systems
When a modification to any air system is to be undertaken plans and specifications as well as a code analysis for compliance with the standards is to be performed by a licensed NYS Engineer prior to any work being performed
IV. Monitoring
The plans and specifications for each installation or change to a system will be reviewed
Director of Facilities Management and reported to the Environment of Care committee
the compliance with the system.
V. Responsibility
The Director of Facilities Management will be responsible for implementing and
documenting all changes to facility.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. No furnishings, decorations, or other objects shall obstruct exits, access thereto, egress there from, or visibility thereof shall be in accordance with 7.1.10. 18.2.1, 19.2.1

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 11, 2016

Citation Details

NFPA 101 2000 LIFE SAFETY CODE STANDARD 7.1.10 Means of Egress Reliability. 7.1.10.1 Means of egress shall be continuously maintained free of all obstructions or impediments to full instant use in the case of fire or other emergency. Based on observation and interview it was determined that the facility did not ensure that all the exit accesses in the facility were so arranged that exit accesses and egress discharge were continuously maintained free of all obstructions to full instant use in accordance with NFPA 101 7.1.10. Reference is made to carts with furniture, overbed table boards and cardboard boxes stored in the corridor obstructing the exit access in the basement of the Friedman building. The findings are On 08/22/16 and 08/23/16 during the life safety code recertification survey between 9:30 am and 3:30 pm, it was observed that the corridor by the engineering office and elevator lobby by the Friedman basement were used to store combustible items such as carts with furniture, overbed table boards and cardboard boxes. A space of approximately 3 feet was available for egress purposes in an emergency. In an interview with the director of environmental services (DES), she stated that the items stored in the corridor will be removed immediately. 2000 NFPA 101- 7.1.10 711.2(a) (1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The area of the(NAME)Basement that was observed to be used to store combustible items such as carts with furniture, over bed table boards and cardboard
boxes were immediately cleaned and the materials appropriately stored and or discarded. 8/26/16
II. Plan to identify other affected areas.
The Director of Environmental Services and the Security Supervisor immediately conducted a survey
of the entire facility to identify any areas that had any obstruction or impediments to full instant use of egress corridors in the event of fire.
III. Measures and Systems
The egress corridors and stair are to be monitored during Security rounds on the evening shift to confirm there are no impediments to egress. All instances of impediments are to be logged on the Security round report and immediately reported to the Environmental Services supervisor on duty or designee to provide immediate corrective action. The weekly facility E(NAME) inspections shall be expanded to include all egress corridors and staircases. Weekly E(NAME) inspections will be documented. On a daily basis the Environmental Services supervisor shall check to see that all basement areas are free from impediments.
IV. Monitoring
The Security Supervisor shall review Security round documentation and follow up on any issues found during the rounds. The Security Supervisor in conjunction with the Environment Service manager check to see if the corrective action was completed. Additionally an investigation as to
what contributing factors or persons led up to the impediment. Results of all surveys and finding
regarding implements shall be reported to the E(NAME) committee at least quarterly for review.

V. Responsibility
The Environment service department supervisor and the Security Supervisor will be responsible
for following up to confirm that the inspection, corrective action and reporting to the Environment
of occurs timely.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Required automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, NFPA 13, NFPA 25, 9.7.5

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: September 21, 2016

Citation Details

NFPA 101 2000 LIFE SAFETY CODE STANDARD Automatic sprinkler systems are continuously maintained in reliable operating condition and are inspected and tested periodically. 19.7.6, 4.6.12, 9.7.5 NFPA 13, NFPA 25, 1998 NFPA 25 Chapter 2-2.1.1 Sprinklers. Sprinklers shall be inspected from the floor level annually. Sprinklers shall be free of corrosion, foreign materials, paint, and physical damage and shall be installed in the proper orientation (e.g., upright, pendant, or sidewall). Any sprinkler shall be replaced that is painted, corroded, damaged, loaded, or in the improper orientation. Based on observation and interview it was determined that the facility did not ensure that all automatic sprinkler heads in the facility were maintained in accordance with NFPA 25, as evidenced by a number of sprinkler heads in facility's Sutro building observed with foreign material (paint) and missing escutcheon plates and numerous sprinkler heads in the Friedman building that were observed with foreign material (paint), installed in the improper orientation, with heavy accumulation of dust, missing caps and with wires attached or sitting on sprinkler heads and pipes. The findings are: On 08/22/16 and 08/23/16 during the life safety recertification survey between 9:30 am and 3:30 pm, it was observed that sprinkler heads in the facility's Friedman and Sutro buildings lacked maintenance. Examples include but are not limited to: Friedman building: - Sprinklers with paint were observed in the basement's electrical shop, corridor by the engineering office, carpenter shop, resident services office, central supply storage room and payroll office. - Sprinklers missing caps were observed on the 1st Fl auditorium, admissions office, ground floor human resources office and H.I.M office. - Wires and cables attached or sitting on sprinkler heads/pipes were observed in the basement central supply storage room, tool shop and corridor by the carpenter shop. - Sprinklers with heavy accumulation of dust were observed in the basement pharmacy. - Sprinklers installed in the improper orientation were observed in basement plumbing shop (twisted pendant sprinkler) and the payroll office (pendant type installed in sidewall orientation) Sutro building: - Sprinklers with paint observed on 1st floor room # T-40 - Sprinkler missing escutcheon plate on 1st Fl porter's closet. In an interview on 08/23/16 with the director of plant operations, he stated that the issues with the sprinkler heads in the facility will be addressed immediately. 2000NFPA 101- 19.7.6, 4.6.12, 9.7.5 1998 NFPA 25- 2-2.1.1, 2-2.1.2 711.2(a) (1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The sprinkler heads in the(NAME)basement and other identified areas were, cleaned, where paint
encroach on the head the heads were replaced, where
incorrectly orientated the heads were reset correctly and or replaced, where subject to attach wires, the attachments were removed and where escutcheons and or caps were missing each was replaced. 9/23/2016
II. Plan to identify other potentially affected areas
The Associate Director of Facilities Management and conducted a full inspection all sprinkler heads with facility to confirm compliance with the code.
III. Measures and Systems
Each event in which a sprinkler head is repaired and or replaced will be inspected by the Associate Director of Facilities Management for correct
application of the sprinkler equipment. Each repair was documented. Engineering staff was inserviced regarding the issue regarding the attachment to sprinkler heads and sprinkler piping.
IV. Monitoring
During weekly Environment of Care Rounds the E(NAME) team will inspect Sprinkler heads for proper installation. The results of these inspections will be reported at the environment of care meeting

V. Responsibility
The Director of Facilities Management will be responsible for maintaining compliance.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Where required by section 19.1.6, Health care facilities shall be protected throughout by an approved, supervised automatic sprinkler system in accordance with section 9.7. Required sprinkler systems are equipped with water flow and tamper switches which are electrically interconnected to the building fire alarm. In Type I and II construction, alternative protection measures shall be permitted to be substituted for sprinkler protection in specific areas where State or local regulations prohibit sprinklers. 19.3.5, 19.3.5.1, NPFA 13

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: January 26, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, it was determined that the facility did not ensure that all areas in the building were protected by an automatic sprinkler system in accordance with section 9.7 and NFPA 13. Reference is made to the lack of sprinkler coverage for the entire facility with the exception of the linen chutes, hazardous areas and some isolated areas scattered throughout the facility. The findings include : On (MONTH) 22 and (MONTH) 23, (YEAR) at 10:00 AM to 3:00 PM, it was observed that the facility consists of three interconnected buildings either via horizontal passage or by sharing exit stairways. The buildings are identified as the Frank, Friedman and the Sutro buildings. The entire facility was not protected by functional automatic fire extinguishing system in accordance with NFPA 13. The following was observed during the life safety code tour of the facility: The areas identified in the findings are not all inclusive. I. Frank Building: Although, the facility had installed sprinkler piping system and sprinklers on the 7th and 5th floors of the building, the system was not yet tied into the water supply system. A number of areas, including but not limited to the following areas lacked sprinkler or the installed sprinklers were obstructed by building structures. (a)Seventh floor (room [ROOM NUMBER]-722)and roof. (1)The elevator machine room lacked fire extinguishing system. (2)The roof storage room lacked automatic sprinklers. (3)The top and bottom of stairs H and I lacked automatic sprinklers. (4)The recessed counter space in room [ROOM NUMBER] lacked sprinkler overage. (5)At least, one storage closet off room [ROOM NUMBER] lacked sprinklers. (6)In the central bathing areas, a solid type curtain installed around the water-closet area obstructed the sprinkler head to not provide coverage for the entire area. (7)Automatic sprinklers were lacking under the approximately 4 1/2 feet wide duct enclosure in the vicinity of the nursing station. (8)In the medication room, the recessed space containing storage counter and cabinets lacked sprinkler coverage. The existing sprinkler was obstructed by a wall to not provide sprinkler coverage for the entire area. (b)Sixth floor (room #s 601-622), had no piping or sprinklers installed. The entire 6th floor consisting of resident rooms, toilet rooms, storage closets, dining room, service areas and bathing areas lacked sprinklers. (c)Fifth floor (room #s 500-522 ) : (1)The accessible storage space above resident's clothes closets had no sprinklers installed. (2)The top of the large pipe shaft lacked sprinklers. (3)The recessed space in the clean linen closet had no sprinkler coverage. The existing sprinkler in the room was obstructed by a wall as not to provide coverage for the entire protected room. (4)The recessed counter space, containing refrigerator ice machine and the coffee maker off the dining room lacked sprinklers. (5)In the central bathing area, a solid type curtain installed around the water closet area off the central bathing area, obstructed the sprinkler head that the entire area was not protected. (6)The recessed space in the oxygen storage room lacked sprinkler coverage. 3rd and 4th Floors. It was observed that the 3rd and 4th floors were not provided with sprinkler protection. It was also noted that sprinkler installation was being conducted in rooms: 406, 404, 402, 401, 403, 405 and 407. SECOND FLOOR The following areas were not sprinkler protected: Rroom #s 223-254 corridors, dining areas, service areas, resident toilet rooms and clothes closets Dining room, Doctor's office, Oxygen storage room and the potter's closet lacked sprinklers. FIRST FLOOR. This area includes the Adult day care center. Only the lobby and the Activities area were sprinklered. Rest of the corridors and rooms were not sprinkler protected. BASEMENT B16 A- second room, storage Closet, security closet, supply closet, housekeeping closet and the mechanical room lacked sprinkler coverage. SUTRO BUILDING ROOF Elevator Machine Room was not provided with any fire extinguishing system. 4th FLOOR Non-sprinklered areas include but not limited to: room [ROOM NUMBER],468, 469,471 including closets, Clean Utility Room, T-20 Optum room, T10, T12, 16 and 19 closets, Electrical closet, Laundry area, and Storage closets. THIRD FLOOR Resident Room #s 369, 372, 370, 371,Bath and Toilet areas and the Electrical rooms had no sprinkler coverage. Second floor: (1)Resident Room #s 260-272 including closets and toilets, the bottom of stair M, central bathing areas, utility closets #s T18, T20, T19, T17, T21, T32A lacked automatic sprinklers. First Floor: The following areas on the Ist floor lacked sprinkler coverage; Room T-10 (tub room), electrical closet, staff lounge/locker room, day room closets, residents' media room, nurse's closet and room #s T16, T18 and T 19. Basement : (1)Section of the corridor in the vicinity of the horizontal exit lacked sprinklers. (2)The lower level beneath the metal grating in the mechanical room containing condensate pump lacked sprinklers. (3)The main electrical rooms were not protected with automatic extinguishing system and did not meet the exception rules in that the door to the room was not 1-1/2 hour fire rated. (4)The small electrical closet was not protected by fire extinguishing system. The exception rule was not met as the closet was being used for storage of wooded dollies and the door to the closet was also not a labeled 1 1/2 hour fire rated door. (5) The toilet room in the vicinity of the linen chute room lacked sprinklers. (6) The bottom of stair B was not sprinklered. In an interview at approximately 1:00PM with the facility's director of engineering, he stated that facility had compiled a listing of areas needing sprinklers in all three buildings and had started installing them. He further stated that all areas in the building will be protected with automatic extinguishing systems in accordance with NFPA 13. Friedman Building: Roof Elevator Motor Room on the roof was not protected with a fire extinguishing system. The top of stair F was not sprinklered. PENTHOUSE (8) Corridors and rooms were not observed with any sprinkler protection. Seventh Floor Top of stair H lacked sprinkler coverage. Several resident rooms and closets were not sprinklered. However, sprinkler installation was going on there. Sixth floor Several rooms, bathrooms and closets as well as the corridor have not been provided with sprinkler coverage. Sprinkler installation was ongoing during the survey. Fifth floor The elevator motor room is not sprinkler protected as well as many resident rooms and the corridor. Fourth floor (room #s 423-454): The 4th floor areas, including resident rooms, corridors, dining room, service areas, resident toilet rooms and clothes closets lacked sprinklers. Third floor (room #s 323-354)The 3rd floor, including resident rooms, corridors, dining areas, service area, resident toilet rooms and clothes closets lacked automatic sprinklers. 2nd floor (room #s 223-254) The 2nd floor, including resident room #s 223-254, corridor, dining areas, service areas, resident toilet rooms and clothes closets lacked sprinklers. 1st floor: Staff room, Cashier/financial offices, bathroom within the admission office, Mission integrated offices, Conference room Friedman 1, Social work services, Speech language office, Physical therapy area, bathroom and closets of Occupational therapy, Volunteer's office and Therapy recreation office lacked sprinkler coverage. Ground Floor: Corridor, security office, dental offices, compressor closet, front desk area and bottom landing of stairway M had no sprinkler coverage. Basement: Boiler water pump room, Freight elevator motor room, Bathroom within female and male locker rooms, Mechanical rooms, absorption equipment room and chiller room, restroom adjacent to absorption equipment room, electrical closet, fan room, IT server room, biohazard/medical waste room, house pump room, electrical meter room (#25) ( did not meet the exception requirement) telecommunication room (B#17), mechanical room [ROOM NUMBER] and room # B15 were not provided with sprinkler coverage. In an interview on 08/23/16 at approximately 2:30 pm with the director of plant operations of the facility (DPO), he stated that currently sprinklers were being installed throughout the facility. 711.2 (a)(1) 2000 NFPA 111 1999 NFPA 13

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for cited areas

The Jewish Home Lifecare, Manhattan has entered into a contract with a NYS licensed engineer for the plans and specifications for a code compliant fire suppression system, hired a competent contractor and started the installation of sprinkler system in accordance with Section 9.7 of the Life Safety code, NFPA 13. and the rules and regulations of the NYCDOB and FDNY. The installation of this sprinkler system and alternate means of fire suppression where local authorities prohibit water based sprinkler will address the issues as cited in all sections of the(NAME)and Sutro buildings.
II. Plan to identify other affected areas
The Director of Facilities Management in conjunction with the facilities NYS licensed design engineer has and will continue to review the ongoing sprinkler installation project to confirm it meets with the NFPA 13 standard for the installation of water based sprinkler systems.
III. Measures and Systems
The installation of the sprinklers are being inspected by a licensed Engineer for piping installation and overall system placement, a licensed fire stopping inspector is inspecting all fire stopping of pipe penetrations and final inspection and project by the Engineer, DOB and FDNY. Training of staff in the use and maintenance of the new system will be implemented before the system is made active. Maintenance of the system will be done under the regulations as outlined in NFPA 25.
IV. Monitoring
The installation of the sprinkler system will be documents as to location, floor and number of heads installed throughout the project to confirm percentage of completion.
V. Responsibility
The Director of Facilities Management will be responsible for maintaining of all documents during installation Monitor the activities of the contractor, inspectors and engineers.

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 26, 2016
Corrected date: October 5, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Physical Plant Violation - State Only Violations NYCRR 713-2.22 (g)(2) A nurses' call emergency button shall be provided for residents' use at each residents' toilet, bath and shower room. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that a nurses' call emergency button was provided at each resident's toilet room. Reference is made to the lack of emergency nurses' call button at the toilet room off the beauty parlor located on the pent house floor of the Friedman Building. The findings include : On (MONTH) 23, (YEAR) at 10:00 AM to 3:00 PM, it was observed that the toilet room for residents' use off the beauty parlor on the penthouse floor in the Friedman Building was not provided with an emergency nurses' call button. On (MONTH) 23, (YEAR) at approximately 1:00 PM, the facility's director of engineering stated that an emergency nurses' call button will be installed in the toilet room.
713-2.22 electrical requirements (f) The electrical circuit(s) to fixed or portable equipment in hydrotherapy units shall be provided with five milliampere ground fault interrupters. Based on observation and interview it was determined that the facility did not ensure that the portable hydrotherapy equipment in the occupational therapy area in the Friedman building was provided with ground fault circuit interrupters. The findings are: On 08/22/16 and 08/23/16 during the life safety recertification survey between 9:30 am and 3:30 pm, it was observed that two [MEDICATION NAME] in the occupational therapy area in the Friedman building were plugged into wall receptacles that lacked ground fault circuit interrupters (GFCI). In an interview on 08/23/16 with the director of environmental services (DES), she stated that the equipment will be provided with GFCI as required by the code. 711.2(a) (1)

Plan of Correction: ApprovedNovember 4, 2016

I. Plan for Cited Area
The toilet room located at the(NAME)Penthouse Beauty Parlor which lacked an emergency call system has had one installed. 9/23/2016
II. Plan to identify other affected areas.
An examination by the Director and Associate Director of Facilities Management was conducted of all of the bath and toilet facilities that are utilized for resident care or services were inspected to confirm that they were equipped with a nurse call device.
III. Measures and Systems
The newly installed nurse call station will be added to the Security local nurse call inspection list for testing on a monthly basis. Beauty parlor staff have been instructed in the operation of the
new emergency call system.

IV. Monitoring
The Security Supervisor shall review the Security inspection logs to confirm that the inspections have been completed timely and any system deficiencies or problems have been corrected. He shall document all reports of system problems.
V. Responsibility
Security Supervisor/ Associate Director of Facilities Management Shall be responsible for the inspection, documentation and repair of the local emergency call systems.