Fox Run at Orchard Park
August 3, 2017 Certification/complaint Survey

Standard Health Citations

FF10 483.25(d)(1)(2)(n)(1)-(3):FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES

REGULATION: (d) Accidents. The facility must ensure that - (1) The resident environment remains as free from accident hazards as is possible; and (2) Each resident receives adequate supervision and assistance devices to prevent accidents. (n) - Bed Rails. The facility must attempt to use appropriate alternatives prior to installing a side or bed rail. If a bed or side rail is used, the facility must ensure correct installation, use, and maintenance of bed rails, including but not limited to the following elements. (1) Assess the resident for risk of entrapment from bed rails prior to installation. (2) Review the risks and benefits of bed rails with the resident or resident representative and obtain informed consent prior to installation. (3) Ensure that the bed?s dimensions are appropriate for the resident?s size and weight.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2017
Corrected date: September 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation, interview and record review conducted during the Standard Survey completed on 8/3/17, the facility did not ensure that each resident receives adequate supervision and assistance to prevent accidents. One (Resident #24) of one resident reviewed for accidents had an issue with the lack of limited assistance during meals as planned and lack of follow-up and professional assessment of the resident's swallowing after staff observed the resident pocketing food in the oral cavity after meal consumption. The finding is: 1. Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS - a resident assessment tool) dated 6/24/17 revealed the resident has moderate cognitive impairment, sometimes understands and is sometimes understood. In addition, the MDS documented that the resident has no swallowing deficit and requires limited assistance with eating. Review of an Occupational Therapy MDS Screen dated 6/13/17 revealed the resident had a left sided cerebral infarct (stroke), has a right facial droop and requires limited assistance with feeding and food cut up into small pieces. Review of a Nutrition Risk assessment dated [DATE] revealed the resident feeds himself independently. The physical examination did not indicate that the resident pocketed food and/or had dysphagia (swallowing difficulty). The Nutrition Risk Assessment documented that the resident receives a regular diet with regular liquids which is tolerated well; the responsible party stated that the resident does well with food cut into small pieces; and the resident requires limited assistance for feeding with adaptive equipment in place. Review of the Physician Admission and History dated 6/13/17 revealed the resident has a history of COPD and a CVA in 2013; over the last few months the resident's health status has declined; and he was receiving Hospice services at home prior to admission. The Physical Examination documented that the resident has a facial droop. Review of the comprehensive Care Plan (CCP) dated 6/15/17 revealed the resident has the potential for altered communication due to the CVA and right sided facial drooping and potential problems with self-care related to COPD, status [REDACTED]. In addition, the CCP documented that the resident is at nutrition risk with interventions to provide a regular diet with regular liquids; provide necessary assistance at meal times; allow the resident to eat at his own pace; and monitor food and fluid intake. Intermittent observations on 7/31/17 and 8/1/17 during breakfast and lunch and on 8/2/17 during breakfast revealed the resident was eating his breakfast in his room independently in bed without staff assistance or monitoring. On 8/2/17 at approximately 9:00 AM, the resident was independently eating oatmeal with whole raisins and had a pronounced right sided facial droop. Additional observation on 8/2/17 at approximately 9:30 AM revealed the resident's breakfast tray was removed and the resident was in bed watching television. Additional observation on 8/2/17 at approximately 10:55 AM revealed a Hospice Certified Nursing Assistant (CNA) provided oral care to Resident #24 and removed food debris from the resident's mouth. The emesis (vomit) basin contained approximately one teaspoon of unchewed oatmeal and whole raisins seen earlier on the resident's breakfast tray. The CNA used a toothbrush to brush the resident's teeth. When the CNA provided water to rinse the resident's mouth, he began coughing up copious amounts of light yellow phlegm, and the CNA provided assistance clearing the phlegm from the resident's mouth into the emesis basin. During an interview on 8/2/17 at approximately 10:58 AM, the Hospice CNA stated that she removes food debris from the resident's mouth all the time when she provides oral care and stated that she provides electronic reports of her care which are submitted to Hospice. During an interview on 8/3/17 at approximately 8:15 AM, the Registered Nurse (RN) Supervisor stated the resident does not have any problems eating and that he did have a swallowing evaluation because he entered the facility on a regular diet. The RN Supervisor stated that Hospice staff communicate with the facility staff daily and she did not receive any report of solid foods being removed from the resident's mouth during oral care the day before. The RN Supervisor stated that staff should probably inform her if that is happening. During an interview on 8/3/17 at approximately 8:46 AM, the Occupational Therapist (OT) stated that when she completed the resident's initial evaluation on 6/13/17, the resident required limited assistance with eating, specifically verbal cuing, and she was just looking at the food. The OT stated she did not see any pocketing of food and the resident had no dripping or coughing on intake; however, she did not perform an inspection of the resident's oral cavity after chewing. The OT stated the resident does have a right sided paresis (muscular weakness caused by nerve damage or disease) from an old stroke. The OT stated if staff are removing solid food from the resident's mouth during oral care, the OT should be informed to provide further evaluation. During an interview on 8/3/17 at approximately 11:50 AM, the Diet Technician stated that she and the previous Registered Dietician (RD) performed the initial Nutrition Risk assessment dated [DATE]. The Diet Technician stated the RD completed the resident's physical examination; the RD inspects the mechanics of how the resident eats/ swallows; and the RD is no longer employed at the facility. Review of a policy and procedure (P&P) entitled Evaluation PT (physical therapy)/OT dated (MONTH) 2010 and identified as current, revealed it is the policy of the facility to assess the resident's ADL (activities of daily living) functional status to plan appropriate treatment. Review of a P&P entitled Swallowing Disorders dated (MONTH) 2007 and identified as current, revealed it is the policy of the facility to have an assessment of the oral phase of the swallowing structure and function to plan appropriate food consistency. The policy does not define which resident conditions/ [DIAGNOSES REDACTED]. 415.12(h)(2)

Plan of Correction: ApprovedSeptember 7, 2017

483.25(d)(1)(2)(n)(1)-(3) FREE OF ACCIDENT HAZARDS/SUPERVISION/DEVICES
1. The facility will ensure that each resident receives adequate supervision and assistance to prevent accidents by assigning a staff member to each resident.
2. Resident #24 was moved to the Dining Room for all meals to ensure proper assistance was provided by staff. If any resident requires assistance and requests to eat in their room per resident choice, a staff member will remain in room with resident while eating.
3. All disciplines including Therapy, Dietary and Nursing will assess the resident upon admission and as needed. Dietary will complete a Nutritional Risk Assessment, an Occupational Therapy screen will assess functional ability for feeding, and a RN will complete the Nursing Admission Assessment which includes ADL activity. All residents currently in-house will be re-evaluated/re-assessed to ensure that all residents are receiving the appropriate level of assistance and adequate supervision and assistance with safe eating/swallowing/nutrition.
4. The DON/designee will in-service all staff on assisting residents as stated on care plan to ensure that all residents receive adequate supervision and assistance with safe eating/swallowing/nutrition. In addition, all staff will be in-serviced and educated on reporting any/all eating/swallowing/nutritional issues to the Supervisor. SNF staff will educate all Hospice staff assisting residents when a new case opens to ensure that Supervisor is updated with any/all issues in residents eating/swallowing/nutrition.
5. All staff/disciplines will continue to monitor resident's eating skills in the Dining Room or resident's room per choice to ensure that resident maintains safe eating skills. All staff/disciplines will report any/all findings or changes in eating skills/intake/swallowing to Nursing Supervisor, to be forwarded to MD for further evaluation. MD will determine need for any additional evaluations.
6. All three (3) meals will be randomly audited every month x six (6) months with a minimum of ten (10) residents by DON/designee to ensure that residents receive adequate supervision and assistance to maintain safe eating skills and ensure proper nutritional/dietary needs are met. Audits will be brought to QAA committee on a quarterly basis to be reviewed for continuance.
7. Overall responsibility to ensure corrective action is implemented with be with the DON. Completion date is (MONTH) 7, (YEAR).


FF10 483.20(e)(k)(1)-(4):PASRR REQUIREMENTS FOR MI & MR

REGULATION: (e) Coordination. A facility must coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in subpart C of this part to the maximum extent practicable to avoid duplicative testing and effort. Coordination includes: (1) Incorporating the recommendations from the PASARR level II determination and the PASARR evaluation report into a resident?s assessment, care planning, and transitions of care. (2) Referring all level II residents and all residents with newly evident or possible serious mental disorder, intellectual disability, or a related condition for level II resident review upon a significant change in status assessment. (k) Preadmission Screening for individuals with a mental disorder and individuals with intellectual disability. (1) A nursing facility must not admit, on or after January 1, 1989, any new residents with: (i) Mental disorder as defined in paragraph (k)(3)(i) of this section, unless the State mental health authority has determined, based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission, (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services; or (ii) Intellectual disability, as defined in paragraph (k)(3)(ii) of this section, unless the State intellectual disability or developmental disability authority has determined prior to admission- (A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for intellectual disability. (2) Exceptions. For purposes of this section- (i)The preadmission screening program under paragraph(k)(1) of this section need not provide for determinations in the case of the readmission to a nursing facility of an individual who, after being admitted to the nursing facility, was transferred for care in a hospital. (ii) The State may choose not to apply the preadmission screening program under paragraph (k)(1) of this section to the admission to a nursing facility of an individual- (A) Who is admitted to the facility directly from a hospital after receiving acute inpatient care at the hospital, (B) Who requires nursing facility services for the condition for which the individual received care in the hospital, and (C) Whose attending physician has certified, before admission to the facility that the individual is likely to require less than 30 days of nursing facility services. (3) Definition. For purposes of this section- (i) An individual is considered to have a mental disorder if the individual has a serious mental disorder defined in 483.102(b)(1). (ii) An individual is considered to have an intellectual disability if the individual has an intellectual disability as defined in §483.102(b)(3) or is a person with a related condition as described in 435.1010 of this chapter. (k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: August 3, 2017
Corrected date: September 7, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review conducted during the Standard survey, completed on 8/3/17, the facility did not ensure that SCREEN Forms DOH (Department of Health)-695 were completed as required. Specifically, one (Resident #24) of two residents receiving Hospice Services reviewed for preadmission SCREENS did not have the SCREEN completed by a qualified screener. The finding is: 1. Resident #24 was admitted to the facility on [DATE] and has [DIAGNOSES REDACTED]. Review of the Minimum Data Set (MDS-a resident assessment tool) dated 6/20/17 revealed the resident is moderately impaired for decision making. Review of a SCREEN Form DOH-695 (2/2009) dated 6/5/2017 revealed the Screener Identification Number had only five digits as opposed to the required ten digits. Interview with the Admissions Coordinator on 8/2/17 at 11:24 AM revealed the individual that completed the SCREEN is not certified to complete SCREENS. The individual that completed the SCREEN works for Hospice and doesn't know the process for completion. Usually, we have an independent Screener complete the SCREENS when the resident is admitted from home or the community. We will have someone come in today and complete the SCREEN. During a later interview with the Admission Coordinator on 8/3/17 at 11:50 AM revealed it is her responsibility to make sure the SCREEN is complete prior to the resident being admitted to the facility but was not aware there needed to be a ten- digit screener identification number and would be looking for that in the future. 400.11

Plan of Correction: ApprovedSeptember 7, 2017

483.20 (e)(k)(1)-(4) PASRR REQUIREMENTS FOR MI & MR
1. The facility will coordinate assessments with the pre-admission screening and resident review (PASARR) program under Medicaid in sub-part C by ensuring that all residents admitted to facility have a pre-admission screen that is completed by a qualified screener.
2. The facility immediately notified Hospice of screen only having 5 digits instead of the required 10 digits. The facility immediately arranged to have a qualified screener come in to complete screen on Resident #24 within the hour and a new qualified screen was given to surveyor.
3. The DON/designee will review with Admissions Coordinator to check that all PRI's have required 5 digits and all screens have required 10 digits prior to admission, and are signed and dated.
4. All residents being admitted from home/community will have PRI/screen completed by independent screener that is properly certified. A monthly audit will be completed on new admissions by DON/designee to ensure compliance. Audits will be brought to QAA committee to be reviewed for continuance.
5. Overall responsibility to ensure action is implemented will be with DON. Completion date is (MONTH) 7, (YEAR).

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: August 3, 2017
Corrected date: September 1, 2017

Citation Details

Based on observation and interview during the Life Safety Code survey completed on 8/3/17, means of egress corridors were not kept clear and unobstructed. Issues included, in locations where the corridor was at least eight feet wide, furniture obstructed immediate access to an exit stair, was not fixed in place, and was located on both sides of the corridor. This affected one of one resident unit. The findings are: 1. Observation on 8/3/17 at approximately 9:35 AM revealed one upholstered chair and one nightstand were located at the end of the eight-foot-wide corridor between Resident Room # 416 and the door to Exit Stair 4. Further observation revealed an illuminated exit sign was present at this location. Additionally, it was observed that the nightstand measured approximately two feet wide by two feet deep, was located approximately two feet away from the door to Exit Stair 4, and obstructed approximately 18 inches of the 34-inch-wide door. The upholstered chair and nightstand were not fixed to the floor or wall. 2. Observation on 8/3/17 at approximately 9:46 AM revealed one upholstered chair, one wooden chair with upholstered seat, and a side table were located in the 12-foot-wide corridor outside of Resident Room # 449. Further observation revealed an illuminated exit sign was present at this location. Additionally, it was observed that another wooden chair with upholstered seat was located directly across the corridor. The chairs and side table in this location were not fixed to the floor or wall. Interview with the Facilities Supervisor on 8/3/17 at approximately 1:00 PM revealed this furniture has always been located in the corridors and it is used by residents. Per the 2012 edition of the National Fire Protection Association (NFPA) 101 Life Safety Code, where the corridor width is at least eight feet, fixed furniture is permitted when it is securely attached to the floor or wall, is located only on one side of the corridor, and is located so as to not obstruct access to building service and fire protection equipment. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.2, 19.2.1, 19.2.3.4, 19.2.3.5

Plan of Correction: ApprovedSeptember 1, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** NFPA 101 Aisle, Corridor, or Ramp Width
1. The facility will ensure that the corridors are kept clean and unobstructed as per NFPA 101 Life Safety Code.
2. The facility immediately removed the nightstand located between Resident room [ROOM NUMBER] and the door to Exit Stair 4. The upholstered chair was moved so as not to obstruct the exit and was affixed to the floor.
3. The facility affixed the upholstered chair and the side table to the floor on one side of the corridor that are located outside Resident room [ROOM NUMBER]. Both wooden chairs with upholstered seats were removed.
4. A 100% audit of all corridor furniture in the Skilled Nursing Facility was completed on 8/4/2017 by the Director of Facilities to ensure that no other areas were non-compliant.
5. The Director of Facilities will instruct the Maintenance Department to check the furniture on their daily rounds to ensure furniture remains affixed to the floor, and that additional furniture is not moved from elsewhere in the facility to resident corridors.
6. A monthly audit will be completed for 12 months by the Director of Facilities/designee to ensure that all furniture remains affixed to the floor on one side of the corridor. Audits will be brought to QAA committee on a quarterly basis to be reviewed for continuance.
7. Overall responsibility to ensure action is implemented is with the Director of Facilities. Completion date is (MONTH) 1, (YEAR).

K307 NFPA 101:COOKING FACILITIES

REGULATION: Cooking Facilities Cooking equipment is protected in accordance with NFPA 96, Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, unless: * residential cooking equipment (i.e., small appliances such as microwaves, hot plates, toasters) are used for food warming or limited cooking in accordance with 18.3.2.5.2, 19.3.2.5.2 * cooking facilities open to the corridor in smoke compartments with 30 or fewer patients comply with the conditions under 18.3.2.5.3, 19.3.2.5.3, or * cooking facilities in smoke compartments with 30 or fewer patients comply with conditions under 18.3.2.5.4, 19.3.2.5.4. Cooking facilities protected according to NFPA 96 per 9.2.3 are not required to be enclosed as hazardous areas, but shall not be open to the corridor. 18.3.2.5.1 through 18.3.2.5.4, 19.3.2.5.1 through 19.3.2.5.5, 9.2.3, TIA 12-2

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2017
Corrected date: August 23, 2017

Citation Details

Based on observation, interview and record review during a Life Safety Code survey completed on 8/3/17, a kitchen hood extinguishment system was not properly maintained. Issues included an in-use kitchen hood extinguishment system that was not in compliance with the National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations. This affected one of one resident unit. The finding is: 1. Observation in the Skilled Nursing Facility Servery on 8/2/17 at approximately 12:15 PM revealed the pull station for the kitchen hood extinguishment system had a red Non-Compliance Inspection Notice tag dated 6/20/17 attached to it. Further observation at this time revealed the tag was placed there by the outside contractor during the last semi-annual inspection of the system and it had a hole punch next to the phrase, lack of automatic fuel shutoff(s). Interview with the Lead Maintenance Technician on 8/1/17 at approximately 9:45 AM revealed during the semi-annual inspection on 6/20/17, the outside contractor found that the gas did not shut down. Continued interview revealed repairs were made and the outside contractor came back on 7/27/17 and found that the gas did shut down, but with an approximate 60 second delay. Interview with the Facilities Supervisor on 8/3/17 at approximately 1:15 PM revealed the outside contractor informed her that the 60 second delay in gas shut down was due to wiring from the initial construction of this building. Review of the outside contractor's most recent service call dated 7/27/17 revealed the following notes: There is a 60 second delay for gas shut down, checked alarm delay on bocce doors, alarm sounds at about a minute, tested Ansul, all gas shut down. Review of an undated written statement from the outside contractor revealed the following notes: The alarm company that installed the fire alarm system must have put a 60 second delay on the shut down at the time of installation. The system was red tagged by our inspectors, but the technician that repaired the shut down issue forgot to remove the red tag. The system is now operational with a 60 second delay on gas shut down as of 7/27/17. Per the 2011 edition of the National Fire Protection Association (NFPA) 96 Standard for Ventilation Control and Fire Protection of Commercial Cooking Operations, upon activation of any fire-extinguishing system for a cooking operation, all sources of fuel and electrical power that produce heat to all equipment requiring protection by that system shall automatically shut off. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.5, 19.3.2.5.1, 9.2.3 2011 NFPA 96: 10.4.1

Plan of Correction: ApprovedAugust 23, 2017

NFPA 101 Cooking Facilities
1. The facility will follow the National Fire Protection Association (NFPA) 96 standard for ventilation control and fire protection for commercial cooking operations by ensuring that all fuel and electrical power that produce heat to all equipment requiring protection by that system will automatically shut off.
2. An outside contractor was hired and removed the 60-second delay on the the kitchen hood extinguishment system on 8/4/2017. System was tested and certified with no 60-second delay. System will continue to be inspected and certified semi-annually by an outside contractor.
3. The Director of Facilities will instruct Maintenance Department to inspect all equipment that is red-tagged. Maintenance Department will make sure contractors remove red tag once equipment is fixed and compliant.
4. Director of Facilities/designee will audit work of outside contractor during every service call to ensure that the Facility is in compliance with NFPA 96 standard for ventilation control and fire protection for commercial cooking operations. Audits will be brought to QAA committee to be reviewed for continuance after 12 months.
5. Overall responsibility to ensure action is implemented will be with the Director of Facilities. Completion date is 8/23/2017.

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Alarm Annunciator A remote annunciator that is storage battery powered is provided to operate outside of the generating room in a location readily observed by operating personnel. The annunciator is hard-wired to indicate alarm conditions of the emergency power source. A centralized computer system (e.g., building information system) is not to be substituted for the alarm annunciator. 6.4.1.1.17, 6.4.1.1.17.5 (NFPA 99)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2017
Corrected date: September 6, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 8/3/17, the facility's emergency generator was not connected to a remote alarm annunciator that was provided to operate outside of the generating room, in a location readily observed by operating personnel at a regular work station. This affected one of one emergency generator, that provided emergency backup power to one of one resident unit. The finding is: 1. Observation in the Service Corridor, located on the First Floor, on 7/31/17 at approximately 9:40 AM revealed the facility's emergency generator was located inside the Communications Room. Further observation revealed an annunciator panel was located within the same room. Observation and interview with the Lead Maintenance Technician on 8/2/17 at approximately 10:30 AM revealed there was no remote annunciator panel at the Nurses' Station and he did not believe the facility had a remote annunciator panel for the generator located outside of the generator room. Observation and interview with the Facilities Supervisor on 8/2/17 at approximately 3:00 PM revealed there was no remote annunciator panel in The Commons area and she did not believe the facility had a remote annunciator panel for the generator located outside of the generator room. Per the 2012 edition of the National Fire Protection Association (NFPA) 99: Health Care Facilities Code, a remote annunciator that is storage battery powered shall be provided to operate outside of the generating room in a location readily observed by operating personnel at a regular work station. The annunciator shall be hard-wired to indicate alarm conditions of the emergency or auxiliary power source as follows: (1) Individual visual signals shall indicate the following: (a) When the emergency or auxiliary power source is operating to supply power to load (b) When the battery charger is malfunctioning 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 99: 6.4, 6.4.1.1.17

Plan of Correction: ApprovedSeptember 1, 2017

NFPA 101 Electrical Systems - Essential Electric Systems
1. The facility will ensure that the emergency generator is connected to a remote alarm annunciator in a location readily observed by operating personnel at a regular work station.
2. A remote alarm annunciator for the facility generator will be installed at the Skilled Nursing Desk, which is staffed 24 hours per day.
3. The new remote alarm annunciator will be checked bi-weekly by the Maintenance Department during routine generator tests to ensure proper functioning. Date will be added to the generator log book on a bi-weekly basis.
4. The Director of Facilities/designee will audit the generator log book on a monthly basis. Audits will be brought to the QAA committee quarterly for one calendar year to be reviewed for continuance.
5. Overall responsibility to ensure action is implemented is with the Director of Facilities. Completion date is (MONTH) 1, (YEAR).

K307 NFPA 101:ELECTRICAL SYSTEMS - ESSENTIAL ELECTRIC SYSTE

REGULATION: Electrical Systems - Essential Electric System Maintenance and Testing The generator or other alternate power source and associated equipment is capable of supplying service within 10 seconds. If the 10-second criterion is not met during the monthly test, a process shall be provided to annually confirm this capability for the life safety and critical branches. Maintenance and testing of the generator and transfer switches are performed in accordance with NFPA 110. Generator sets are inspected weekly, exercised under load 30 minutes 12 times a year in 20-40 day intervals, and exercised once every 36 months for 4 continuous hours. Scheduled test under load conditions include a complete simulated cold start and automatic or manual transfer of all EES loads, and are conducted by competent personnel. Maintenance and testing of stored energy power sources (Type 3 EES) are in accordance with NFPA 111. Main and feeder circuit breakers are inspected annually, and a program for periodically exercising the components is established according to manufacturer requirements. Written records of maintenance and testing are maintained and readily available. EES electrical panels and circuits are marked, readily identifiable, and separate from normal power circuits. Minimizing the possibility of damage of the emergency power source is a design consideration for new installations. 6.4.4, 6.5.4, 6.6.4 (NFPA 99), NFPA 110, NFPA 111, 700.10 (NFPA 70)

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2017
Corrected date: August 23, 2017

Citation Details

Based on interview and record review during a Life Safety Code survey completed on 8/3/17, the emergency generator was not properly maintained. Issues included, the facility did not consistently conduct weekly inspections of the emergency generator. This affected one of one emergency generator, that provided emergency backup power to one of one resident unit. The finding is: 1. Record review of the Weekly Generator Checkoff Sheet revealed the facility did not have documentation of weekly inspections for the emergency generator between 10/29/16 and 12/1/16. Interview with the Facilities Supervisor on 8/1/17 at approximately 10:00 AM revealed the weekly generator checks were overlooked during (MONTH) (YEAR) and this was probably due to a personnel change that occurred at that time. 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.5.1, 19.5.1.1, 9.1.3, 9.1.3.1 2010 NFPA 110: 8.3.4, 8.3.4.1, 8.4, 8.4.1

Plan of Correction: ApprovedAugust 23, 2017

NFPA 101 Electrical Systems - Essential Electrical Systems
1. The Facility will conduct weekly inspections on the emergency generator and record findings on the Weekly Generator Checkoff Sheet as scheduled.
2. The Director of Facilities will in-service all Maintenance Staff on weekly inspection procedure.
3. The Director of Facilities/designee will audit the Weekly Generator Checkoff sheet on a monthly basis to ensure that weekly inspections are completed. Audits will be brought to the QAA committee to be reviewed for continuance.

4. Overall responsibility to ensure action is implemented will be with the Director of Facilities. Completion date is (MONTH) 23, (YEAR).

K307 NFPA 101:GAS EQUIPMENT - CYLINDER AND CONTAINER STORAG

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: August 3, 2017
Corrected date: September 1, 2017

Citation Details

Based on observation and interview during a Life Safety Code survey completed on 8/3/17, signage stating that oxygen was stored within a room was not present. This affected one of one resident unit. The findings are: 1. a) Observation in the large Dining Room on 7/31/17 at approximately 9:55 AM revealed one E sized oxygen cylinder was stored on a crash cart and the door to the room was not equipped with a sign stating that oxygen was stored within. b) Observation in the small Dining Room on 7/31/17 at approximately 10:00 AM revealed one E sized oxygen cylinder was stored on a crash cart and the door to the room was not equipped with a sign stating that oxygen was stored within. Interview with the Registered Nurse Supervisor, at the time of these observations, revealed the crash carts with the oxygen cylinders are always stored in the Dining Rooms. Per the 2012 edition of NFPA99 Health Care Facilities Code, A precautionary sign, readable from a distance of 1.5 m (5 ft), shall be displayed on each door or gate of the storage room or enclosure. The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING 10 NYCRR 415.29(a)(2), 711.2(a)(1) 2012 NFPA 101: 19.3.2.4 2012 NFPA 99: 11.3.4, 11.3.4.1, 11.3.4.2

Plan of Correction: ApprovedSeptember 1, 2017

NFPA 101 Gas Equipment - Cylinder and Container Storage
1. The Facility will ensure that signage stating 'oxygen in use/storage' is present on the door frames of all room containing oxygen equipment.
2. The facility immediately applied magnetic 'oxygen in use' signs to the door frames of both the Large and Small Dining Rooms as per NFPA99 Health Care Facilities code.
3. The Maintenance Department will check that 'oxygen in use' signs are posted and clearly visible on weekly inspection rounds. The weekly 'oxygen in use' sign inspections will be documented on the Maintenance checklist.
4. The Director of Facilities/designee will audit the Maintenance checklist on a weekly basis and physically check the signage monthly to ensure compliance. Audits will be brought to the QAA committee on a quarterly basis for one calendar year to be reviewed for continuance.

5. Overall responsibility to ensure action is implemented will be with the Director of Facilities. Completion date is (MONTH) 1, (YEAR).