Crest Manor Living and Rehabilitation Center
September 30, 2016 Certification/complaint 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: September 30, 2016
Corrected date: November 29, 2016

Citation Details

Based on interviews and record reviews conducted during the Recertification Survey and complaint investigation (#NY 797 and #NY 016) completed on 9/30/16, it was determined that for one of three personnel files reviewed, the facility did not ensure that all staff were educated regarding the protection of resident privacy and prohibiting mental abuse related to photographs and audio/video recordings. This is evidenced by the following: Review of the facility investigation, dated 9/9/16, revealed that the Director of Nursing (DON) received a telephone call stating that videos were viewed of a resident that were inappropriate and abusive. The DON was able to view the videos and determine that three Certified Nursing Assistants (CNAs) were responsible. Review of the sign-in sheets for Photographs/Recordings of Residents Policy and Procedure, dated (MONTH) (YEAR), revealed that the CNA that recorded the video was not on the list. When interviewed on 9/14/16 at 10:20 a.m., the DON stated that the alleged CNA videographer had not received the training in August. The undated facility policy Resident Rights and Dementia Training annual mandatory in-service packet did not include social media or audio/video recordings. (10 NYCRR 415.4(b))

Plan of Correction: ApprovedOctober 20, 2016

This Plan of Correction constitutes a written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Element 1
All staff members have been educated on the policy ?Photographs/Recordings of Residents ? Policy and Procedures? dated (MONTH) (YEAR). This policy will become part of the employee handbook starting (MONTH) 1, (YEAR).
Element 2
Review of all other employee files was done to ensure all employees were trained on this policy. The review showed that all employees had received training.
Element 3
All new employees will be educated on the policies during orientation with the Staff Educator. The policies will also become part of the mandatory in-services required annually for all employees.
Element 4
The Staff Educator will be responsible for ensuring all staff are educated on new and updated policies and procedures. All staff members will be responsible for implementation of policy.
Element 5
The Staff Educator will be responsible for ongoing 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: September 30, 2016
Corrected date: November 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations, interviews, and record reviews conducted during the Recertification Survey and complaint investigation (#NY 016) completed on 9/30/16, it was determined that one of six residents reviewed for accidents, the facility did not have investigate a bruise to rule out abuse, neglect, or mistreatment. The issue involved bruising that was not identified or investigated. This is evidenced by the following: Resident #12 has [DIAGNOSES REDACTED]. The Minimum Data Set (MDS) Assessment, dated 6/15/16, revealed the resident is cognitively intact. Review of skin notes, dated 6/8/16 and 8/8/16, revealed the resident had a dark purple bruise covering the back of both hands, which was resolved on 8/8/16. The Comprehensive Care Plan, dated 9/20/16, does not address that the resident is at risk for bruising. Review of the Incident and Accident Report, dated 9/29/16, documented that the resident had ecchymotic areas (purplish patch caused by blood under the skin) on the area on the posterior (back) of both hands. The area on the left hand measured 6 centimeters (cm) x 11.5 cm and the area on the right hand measured 9 cm x 8.5 cm. During an observation on 9/27/16 at 10:00 a.m., the resident had two large discolored areas on the back of both hands. When interviewed at that time, the resident stated he bruises easily and always gets bruises. He said if he just bumps into something he bruises . Interviews conducted on 9/29/16 included the following: a. At 1:18 p.m., Certified Nursing Assistant (CNA) #1 stated that she put lotion on the resident's hands that morning but did not notice any bruises. b. At 1:30 p.m., the Registered Nurse (RN) stated that she did not know the resident had any bruises. After surveyor intervention, the RN assessed and measured the bruises and stated she needed to initiate an Incident and Accident Report and start an investigation. The RN said she expects the CNAs to report any skin issues to the Licensed Practical Nurse (LPN) or the RN. She said the nurses do not routinely check the resident's skin on bath/shower days. c. At 1:45 p.m., CNA #2 stated that if she notices any skin issues she immediately reports it to the nurse. When interviewed on 9/30/16 at 10:30 a.m., the Assistant Director of Nursing (ADON) stated if a resident is alert and oriented and states that they were not abused, the investigation stops. The ADON said that the CNA reports any concerns to the nurse and then writes their statement. She said the LPN or RN will assess, measure the area and then interview the resident. The facility policy, Procedure for Incident and Accident Reporting of Unknown Origin, dated (MONTH) 2010, included that staff will be interviewed going back 72 hours or until the cause of the incident is discovered. (10 NYCRR 415.4(b)(3))

Plan of Correction: ApprovedOctober 20, 2016

This Plan of Correction constitutes a written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Element 1
A root cause analysis through the Incident and Accident Report of Resident #12?s ecchymotic areas on hands was completed on (MONTH) 29, (YEAR) after initiation of an Incident and Accident Report. The investigation including staff interviews revealed that there was no credible evidence abuse or neglect occurred to resident #12. The facility counsel and re-educate the all involved employees on the facility policy regarding investigations and reporting of potential resident abuse.
Element 2
A review of all residents to identify additional residents who may have had ecchymotic areas which required investigation, assessments, or changes to care plan occurred. Any issues will be reported per protocol.
Element 3
The facility policy ?Procedure for Incident and Accident Reporting of Unknown Origin? will be reviewed and updated. Once updated, our Staff Educator will educate all staff on the requirements related to abuse & neglect, as well as educate the nursing department on their roles and responsibilities related to the updates in the policy.
Element 4
The DON and ADON are to be responsible for implementation of policies; and the Nurse Managers are responsible for ongoing compliance. Audits of Incidents and Accident reports will be completed by the ADON for 3 months, then quarterly to ensure reporting is in compliance with policies. Visual audits of residents for bruises by Nurse(s) (RN & LPN) and CNA?S will occur for three months, then quarterly to ensure compliance. Results will be discussed at quarterly QAPI meetings for review and action as necessary.
Element 5
Director of Nursing and Assistant Director of Nursing are responsible for ongoing compliance.

FF09 483.20(d)(3), 483.10(k)(2):RIGHT TO PARTICIPATE PLANNING CARE-REVISE CP

REGULATION: The resident has the right, unless adjudged incompetent or otherwise found to be incapacitated under the laws of the State, to participate in planning care and treatment or changes in care and treatment. A comprehensive care plan must be developed within 7 days after the completion of the comprehensive assessment; prepared by an interdisciplinary team, that includes the attending physician, a registered nurse with responsibility for the resident, and other appropriate staff in disciplines as determined by the resident's needs, and, to the extent practicable, the participation of the resident, the resident's family or the resident's legal representative; and periodically reviewed and revised by a team of qualified persons after each assessment.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 30, 2016
Corrected date: November 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #36) of three residents reviewed for Participation in Care Planning, the facility did not ensure the resident/designated representative were afforded the right to participate in their admission care plan meeting. This is evidenced by the following. Resident #36 was admitted on [DATE] with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 5/16/16, documented that the resident had severe impairment of cognitive function and required extensive assistance of staff for activities of daily living. Additionally, the assessment revealed that the resident was involved in the assessment but neither family nor legal guardian were involved. The Interdisciplinary Care Plan, dated 5/16/16, identified the resident is at risk for psychosocial well-being related to being a new admission and that the resident establishes her own goals. Interventions included to keep the family involved and that the resident has a supportive family. A Social Work Note, dated 5/23/16, revealed that the resident is alert and confused and has a supportive family and a daughter who visits regularly. Review of the resident's care plan meeting Attendance Signature Sheets, dated 6/6/16 and again 9/1/16, revealed for both meetings neither the resident nor family signed as attended. During a family interview on 9/28/16 at 9:40 a.m., a family member stated that they have never been invited to a care plan meeting to discuss the resident's care with all the disciplines. Interviews conducted on 9/28/16 include the following: a) At 8:00 a.m., the Nurse Manager (NM) stated the resident has one family member who visits all the time. b) At 1:33 p.m., and again on 9/30/16 at 10:19 a.m., the Social Worker (SW) stated they only invite the residents and their families to the three month care plan meeting, not the comprehensive admission meeting. The SW said she was not sure why. She said that she sent a letter to a family member for the second care plan meeting (signed as held on 9/1/16) but never heard back from them and no one attended. She added that she does not keep a record or a copy of the letters sent. She said she thought she sent it to the Health Care Proxy who she believes is the only family member. The SW said that she agreed that the resident and/or family should be invited to the initial comprehensive meeting but when she questioned this policy, she was told it has always been that way. review of the resident's medical record revealed [REDACTED]. One of several daughters is the one listed as the Power of Attorney, signed the MOLST (medical orders for life sustaining treatments) and is listed on the Hospital Admission and Discharge Identification and Medical Record Summary as the first one to call in case of an emergency. Additionally, this same family member is listed first on the facility Resident Authorization for Use and Disclosure of Protected Health Information. When asked if this family member was invited to either care plan meeting the SW stated, No. Review of the facility policy, Interdisciplinary Care Planning Conference, dated as last revised (MONTH) 2006, revealed that to facilitate interdisciplinary discussion and goal oriented care planning, residents and significant others are included in and/or their input solicited at/or prior to the interdisciplinary meeting. Interdisciplinary Care planning meetings occur within 21 days of admission and at three months. The SW is responsible for scheduling the three month conference and for inviting the resident to the meeting and advising families by mail. (10 NYCRR 415.11(c)(2)(i-iii))

Plan of Correction: ApprovedOctober 20, 2016

This Plan of Correction constitutes a written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Element 1
Review of Resident #36?s care plan was completed. The family has been invited to participate in the care plan meeting. In addition, a Health Care Proxy for Resident #36 has been identified. The facility re-educated Social Work staff on the regulations regarding Interdisciplinary Care Conferences.
Element 2
A review of other residents care plans was initiated to ensure that families had the right to participate in the admission care plan meeting. During this review, no other issues were noted.
Element 3
The facility policy ?Interdisciplinary Care Planning Conference? will be reviewed and updated. Care plan meetings will occur within 21 days of admission, at the three month mark, annually, and if there is a significant change in the resident?s condition. Residents and family will be invited to attend all meetings. Invites will be sent via mail, and Social Work will also contact family by phone. Residents will be invited in person and by a letter. Documentation will be stored in a Care Conference Binder in Social Work.

Element 4
Social Work will be responsible for ensuring compliance at the direction of the Administrator. An audit of the invites and care planning meetings will occur for the next three months, and then quarterly to ensure compliance. Results will be discussed at quarterly QAPI meetings for review and action as necessary.
Element 5
The Director of Social Work will be responsible for ongoing compliance.

FF09 483.25(a)(2):TREATMENT/SERVICES TO IMPROVE/MAINTAIN ADLS

REGULATION: A resident is given the appropriate treatment and services to maintain or improve his or her abilities specified in paragraph (a)(1) of this section.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: September 30, 2016
Corrected date: November 29, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interviews and record reviews, it was determined that for one (Resident #95) of one resident reviewed for rehabilitation, the facility did not provide the appropriate treatment to maintain or improve the resident's functional ability. Specifically, the resident was not ambulated for approximately two weeks, per therapy recommendations. This is evidenced by the following: Resident #95 was admitted on [DATE] for rehabilitation with [DIAGNOSES REDACTED]. A Minimum Data Set (MDS) Assessment, dated 9/3/16, revealed the resident is cognitively intact and requires extensive assist with transfers. Review of the resident's current Comprehensive Care Plan revealed that the resident is at risk for falls related to, but not limited to, a history of falls, weakness, and gait instability. Interventions include transfers per Occupational and Physical Therapy (PT) but does not include ambulation. Review of a PT progress note, dated 9/15/16, included recommendations to nursing for ambulation up to 10 feet with a walker and one assist of staff wearing the Prafo boot on the left lower extremity. It includes that the resident's prognosis is good due to improved potential to improve ambulation when wearing the Prafo boot and due to a significant decrease in discomfort with weight bearing. The Certified Nursing Assistant (CNA) Master Care Plan, dated 9/25/16 through 10/1/16, includes the resident is one assist for transfers and to wear a left foot Prafo boot (specialty boot to reduce pressure to the heel area) during day hours. It does not include ambulation. When interviewed on 9/28/16 at 1:29 p.m., the primary CNA stated the resident walks during therapy but not on the floor. She explained that they do not ambulate her due to the boot on her foot. Interviews conducted on 9/29/16 included the following: a) At 8:42 a.m., the resident stated that she wants to walk more and go home. She added that she walks during therapy but not up here. b) At 1:15 p.m., the Physical Therapist stated that the resident was admitted for rehabilitation with the possibility of long term care. He said that she is still receiving PT for increased ambulation and that she can do approximately 20 feet which would be from her bed to the bathroom. The PT said she can ambulate ok with the boot on, is alert, and does not refuse. He went on to say that the communication procedure includes a written progress note sent to nursing and then nursing updates the care plan. c) At 1:29 p.m., the Nurse Manager (NM) stated that therapy is supposed to put the progress note in the rehab book and the Licensed Practical Nurse adds the recommendations to the care plan. In this case she feels it was a communication issue and the therapy recommendations did not get put in the correct book. She added that this recently happened to another resident and she spoke with therapy to correct it. Review of the facility policy Communicating Care Recommendations from the PT/OT/SLP Department (Restorative Care) to the Nursing Department, dated as last reviewed on 4/27/11, revealed that therapists will document identified needs/nursing recommendations in the rehabilitation section of the resident's medical chart and NMs will have a designated location for therapists to leave their recommendations. It includes that NMs are responsible to communicate therapy recommendations to their care staff by updating the care plan and the CNA master sheets. (10 NYCRR 415.12(a)(2))

Plan of Correction: ApprovedOctober 20, 2016

This Plan of Correction constitutes a written allegation of compliance for the deficiencies cited. However, submission of this Plan of Correction is not an admission that a deficiency exists or that one was cited correctly. This Plan of Correction is submitted to meet requirements established by state and federal law.
Element 1
A review of Resident #95?s therapy notes and care plan was completed. The review showed that the resident?s therapy notes and care plan matched. The facility counseled and re-educated the Nurse Manager and Therapy Coordinator on the facility policy regarding care communications from the therapy department to nursing department.
Element 2
A review of other resident?s charts was initiated to ensure that Therapy Notes and Care Plans matched. During this review, no other issues were noted.
Element 3
The facility policy ?Communicating Care Recommendations from the PT/OT/SLP Department (Restorative Care) to the Nursing Department? has been reviewed and updated. Therapists will document identified needs in the rehabilitation section of the chart, as well as leave recommendations in a therapy binder at the nurse?s station. This binder will be reviewed daily by the Nurse Manager who will be responsible for updating the care plan and the CNA Masters sheet. A LPN may update the care plan and CNA Masters Sheet with therapy recommendations and the RN will co-sign the order.
Element 4
Nurse Managers and Therapy Coordinators will be responsible for ensuring compliance. An audit of therapy notes and residents care plans will be conducted for three months, then quarterly to ensure that documentation is in compliance with the policies. Results will be discussed at quarterly QAPI meetings for review and action as necessary.
Element 5
Nurse Manager and Therapy Coordinator will be responsible for ongoing compliance at the direction of the Director of Nursing.

Standard Life Safety Code Citations

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Building construction type and height meets one of the following: 19.1.6.2, 19.1.6.3, 19.1.6.4, 19.3.5.1

Scope: Widespread
Severity: Potential to cause more than minimal harm
Citation date: September 30, 2016
Corrected date: September 30, 2016

Citation Details

Based on observations and record review conducted during the Life Safety Code Survey, it was determined that for three of three resident use floors, the facility did not provide an approved building construction type for a three story health care facility. The issue was related to structural supports that were not protected with a proper fire resistant material. The findings are: The 2000 edition of NFPA 101, Life Safety Code requires that an existing health care building that is three stories tall and is fully sprinklered must have its structural supports protected from fire by a one-hour fire rated material. Observations above the suspended ceiling on 9/29/16 from 8:46 a.m. to 9:12 a.m. revealed the horizontal structural supports on the first, second, and third floors of the original building (1972) were not protected with a fire resistive material capable of resisting fire. Red steel I-beams and joists were observed in the area above the suspended ceilings on all three floors, supporting the weight of the concrete decks above them. (10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000:19.1.6.2)

Plan of Correction: ApprovedOctober 21, 2016

1) The facility shall continue with this provision of the Life Safety Code based on maintaining the Fire Safety Evaluation System until formal review is completed by the New York State Department of Health?s Bureau of Architectural and Engineering Facility Planning.
2) The Administrator shall be responsible for the correction of the deficiency and to ensure all measures of compliance related to this deficiency are followed.
3) The FSES will be reviewed at the Quarterly Quality Assurance meetings for interdisciplinary review.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 30, 2016
Corrected date: September 30, 2016

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for three of three resident use floors, the facility did not maintain electrical installations. Specifically, non Underwriters Laboratories (UL)1363 plug strips were used in resident rooms, plug strips were daisy chained, plug strips were broken and a plug extender was in use. The findings are: Observations conducted in the presence of the Director of Maintenance on 9/27/16 between 9:45 a.m. and 11:25 a.m. revealed the following: a. The Activities Room had a 3-outlet plug extender in use with a plug strip plugged into it. b. There was a plug strip in the Personal Care Room mounted to the wall which was broken in several locations. Pieces of the plastic housing were missing in the broken locations. c. In Resident room [ROOM NUMBER] there were two plug strips in use, one Belkin and one Power Century, which did not have a UL1363 designation printed on them. In an interview at that time, the Director of Maintenance stated that the Power Century was brought in by the family so they won't have documentation. The surveyor requested documentation for the Belkin plug strip. d. In Resident room [ROOM NUMBER] there were two plug strips, one Belkin and one with no brand name. Neither plug strip had a UL1363 listing printed on the strip. e. In the Admission's office there was a plug strip plugged into a plug strip. The plug strips were providing power to multiple pieces of computer equipment. No further documentation regarding UL listing could be provided for the Belkin, Power Century, or the plug strip with no brand name listed on it. The 1999 edition of NFPA 70, National Electrical Code, requires that listed or labeled equipment shall be installed and used in accordance with any instructions included in the listing or labeling. There shall be no damaged parts that may adversely affect safe operation or mechanical strength of the equipment such as ports that are broken. Where used as permitted, each flexible cord shall be equipped with an attachment plug and shall be energized from a receptacle outlet. S&C 14-46-LSC states that power strips providing power to patient care-related electrical equipment must be Special-purpose Relocatable Power Taps (SPRPT) listed as UL 1363A or UL -1. Power strips providing power to non- patient-care-related electrical equipment must be Relocatable Power Taps (RPT) listed as UL 1363. (10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000: 19.5.1, 9.1.2, 1999 NFPA 70: Article 110-3, Article 110-12, Article 400-8 S&C 14-16-LSC)

Plan of Correction: ApprovedOctober 21, 2016

The three outlet plug extender (A) in use with a plug strip plugged into was removed by the maintenance staff on 9/28/16 and replaced with a UL-1363 listed plug strip. The plug strip in the personal care room (B) mounted to the wall was removed and replaced by the maintenance staff with a UL-1363 listed plug strip on 9/28/16. The plug strips in resident rooms #307 (C) and #215 (D) were removed by the maintenance staff and replaced with UL-1363 listed plug strips on 9/28/16. The plug strip plugged into a plug strip in the admissions office were removed and replaced by the maintenance staff with a UL-1363 listed plug strip on 9/28/16.
The maintenance staff under the direction of the Maintenance Director inspected all rooms in the building to ensure patient care related electrical equipment are plugged directly into the electrical outlet. Ensure all plug strips connected to electrical devices, with the exception of patient care related electrical equipment are UL-1363 rated, in good working condition and multiple plug strips are not connected/?daisy chained? together.
The Maintenance Director and Administrator will determine the need and quantity of Special Purpose Relocatable Power Taps (SPRPT) UL-1363A or UL- -1 power strips in the building will order the power strips and the maintenance staff will install the power strips in the appropriate locations.
Monthly audits in the facility will be conducted by the maintenance staff under the direction of the Maintenance Director to ensure patient care electrical equipment are plugged directly into an electrical outlet or are connected to a Special Purpose Relocatable Power Taps (SPRPT) UL-1363A or UL- -1 power strips, ensure all plug strips connected to electrical devices, with the exception of patient care electrical equipment are UL-1363 rated, in good working condition and multiple plug strips are not connected/?daisy chained? together.
The Maintenance Director will complete the audits and present the findings at the Quarterly Quality Assurance meetings for interdisciplinary review and corrective action as needed.
The Maintenance Director will be responsible for the correction of this deficiency under the guidance and direction of the Administrator.

K301 NFPA 101:LIFE SAFETY CODE STANDARD

REGULATION: Doors in an exit passageway, stairway enclosure, horizontal exit, smoke barrier or hazardous area enclosure are self-closing and kept in the closed position, unless held open by as release device complying with 7.2.1.8.2 that automatically closes all such doors throughout the smoke compartment or entire facility upon activation of: (a) The required manual fire alarm system and (b) Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system and (c) The automatic sprinkler system, if installed 18.2.2.2.6, 18.3.1.2, 19.2.2.2.6, 19.3.1.2, 7.2.1.8.2 Door assemblies in vertical openings are of an approved type with appropriate fire protection rating. 8.2.3.2.3.1 Boiler rooms, heater rooms, and mechanical equipment rooms doors are kept closed.

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: September 30, 2016
Corrected date: October 19, 2016

Citation Details

Based on observations and interviews conducted during the Life Safety Code Survey, it was determined that for one (first) of four resident use floors, the facility did not maintain doors to hazardous areas. Specifically, doors to hazardous areas did not properly close and make a smoke-tight seal when pulled from their magnets. The findings are: Observations conducted in the presence of the Director of Maintenance on 9/27/16 between approximately 10:46 a.m. and 11:01 a.m. revealed the following: a. The door to the first floor dish room did not close and latch on its own. When the door was closed, the door appeared to get stuck on the floor. When it was pushed past the sticking point, the latch did not operate properly to positively latch into its frame. The dish room was open to the Main Kitchen. b. The door to the Soiled Linen Room located next to the Main Laundry room on the first floor, did not close and latch on its own. c. The door to the Main Laundry room did not close and latch on its own. In an interview at that time, the Director of Maintenance stated that these doors get beat up pretty bad. (10 NYCRR 415.29(a)(2), 711.2(a)(1); NFPA 101 LSC 2000:19.2.2.2.6, 7.2.1.8.2)

Plan of Correction: ApprovedOctober 21, 2016

The door to the first floor dish room (A) and the door to the soiled linen room (B) were repaired on 10/01/16 by the maintenance staff under the direction of the Maintenance Director by making adjustments to the door frames and hinges until both doors operated and latched properly in the closed position.
The door to the main laundry room was repaired by an outside contractor on 10/04/16 by replacing the door and frame with a 90 minute fire rated steel material, parallel arm closure and lever lockets door handle and adjustments made until the door operated and latched properly in the closed position. The maintenance staff under the direction of the Maintenance Director inspected all self-closing doors in hazardous areas to ensure they operated and latched properly in closed position on 9/30/16.
Monthly audits in the facility will be conducted by the maintenance staff under the direction of the Maintenance Director to ensure all doors in hazardous areas operate and latch properly in the closed position.
The Maintenance Director will complete the audits and present the findings at the Quarterly Quality Assurance meetings for interdisciplinary review and corrective action as needed.
The Maintenance Director will be responsible for the correction of this deficiency under the guidance and direction of the Administrator.