Waterview Nursing Care Center
March 16, 2018 Certification/complaint Survey

Standard Health Citations

FF11 483.90(e)(1)(ii):BEDROOMS MEASURE AT LEAST 80 SQ FT/RESIDENT

REGULATION: §483.90(e)(1)(ii) Measure at least 80 square feet per resident in multiple resident bedrooms, and at least 100 square feet in single resident rooms;

Scope: Pattern
Severity: Potential to cause minimal harm
Citation date: March 16, 2018
Corrected date: N/A

Citation Details

The following waiver is on file with this office. Repeat waivers are granted 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. Include your request for renewal of this waiver or plan of correction in the space provided on this form. A total of 56 two-bedded rooms, numbered 1, 3-10, 15, 23, 26, 27, 29, 32 and 34-65 provide 75 square feet per bed in lieu of 80 square feet per bed. 711.5 (c)(7)

Plan of Correction: ApprovedMarch 30, 2018

The facility is respectfully requesting the continuation of the existing waiver for the 56 two-bedded rooms identified as having 75 square feet per bed in lieu of 80 square feet per bed.

Standard Life Safety Code Citations

DEVELOPMENT OF COMMUNICATION PLAN

REGULATION: (c) The [facility] must develop and maintain an emergency preparedness communication plan that complies with Federal, State and local laws and must be reviewed and updated at least every 2 years (annually for LTC).

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the Emergency Preparedness (EP) communication plan complies with Federal, State and local laws. Specifically, the facility did not assign the task of emergency medical supplies receiving office to a staff member. This occurred while reviewing the facility's EP plan. The finding is: On 3/23/2018 and 3/26/2018 between the hours of 8:40am and 3:30pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's EP documentation, it was revealed that the facility did not assign a point of contact for the task of emergency medical supplies receiving office. This was contrary to the requirements of 10NYCRR 400.10 requiring this role to be designated by each facility in the HPN Communications Directory. In an interview with the Administrator at approximately 11am, he stated he thinks only the owner assigns the roles and it will probably be assigned to the Assistant Administrator. 10NYCRR 400.10

Plan of Correction: ApprovedApril 9, 2018

The point of contact for the task of emergency medical supplies receiving office was assigned.
The facility respectfully states that all residents were potentially affected.
The Administrator / designee will conduct quarterly reviews of the Facilities Emergency Offices Roles to ensure they have a point of contact assigned to them. Reviews with negative findings will have corrective actions taken.
Review findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Administrator is responsible for ensuring compliance.

K307 NFPA 101:DOORS WITH SELF-CLOSING DEVICES

REGULATION: Doors with Self-Closing Devices Doors in an exit passageway, stairway enclosure, or horizontal exit, smoke barrier, or hazardous area enclosure are self-closing and kept in the closed position, unless held open by a 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: * Required manual fire alarm system; and * Local smoke detectors designed to detect smoke passing through the opening or a required smoke detection system; and * Automatic sprinkler system, if installed; and * Loss of power. 18.2.2.2.7, 18.2.2.2.8, 19.2.2.2.7, 19.2.2.2.8

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

19.2.2.2.7* Any door in an exit passageway, stairway enclosure, horizontal exit, smoke barrier, or hazardous area enclosure shall be permitted to be held open only by an automatic release device that complies with 7.2.1.8.2. The automatic sprinkler system, if provided, and the fire alarm systems required by 7.2.1.8.2, shall be arranged to initiate the closing action of all such doors throughout the entire facility. 7.2.1.8.2 In any building of low or ordinary hazard contents, as defined in 6.2.2.2 and 6.2.2.3. or where approved by the authority having jurisdiction, door leaves shall be permitted to be automatic- closing, provided that all of the following criteria are met: (1) Upon release of the hold-open mechanism, the leaf becomes self-closing. (2) The release device is designed so that the leaf instantly releases manually and, upon release, becomes self -closing, or the leaf can be readily closed. (3) The automatic releasing mechanism or medium is activated by the operation of approved smoke detectors installed in accordance with the requirements for smoke detectors for door leaf release service in NFPA 72, National Fire Alarm and Signaling Code. (4) Upon loss of power to the hold-open device, the hold-open mechanism is released and the door leaf becomes self-closing. (5) The release by mean of smoke detection of one door leaf in a stair enclosure result in closing all door leaves serving that stair. Based on observation and staff interview, the facility failed to ensure that doors to stairways and hazardous areas were self- closing or automatically closing with activation of the fire alarm system. This occurred on 1 of 3 floors of the facility, including the basement. The finding is: On 3/23/2018 and 3/26/2018 between the hours of 8:45am and 3:30pm during the recertification survey, the following was observed: On the 1st floor, the Electric Switch Gear room contained storage of electrical equipment. The door contained a hold open device that impeded the self- closing device. In the basement of the facility, the exit stair door located adjacent to the laundry room did not self- close. In an interview with the Director of Maintenance at approximately 12:20pm, he stated he can remove the door catch. In an interview with the Director of Maintenance at approximately 1:20pm, he stated he can add a self- closing device. 2012 NFPA101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 9, 2018

? The hold open device on the door to the Electric Switch Gear room was removed
? A self-close device was added to the exit stair door located adjacent to the laundry room
The Director of Environmental Services / designee conducted an audit of doors to stairways and hazardous areas to ensure they are self-closing or automatically closing with activation of the fire alarm system and that there are no devices impeding the self-closing device.
The Director of Environmental Services / designee will conduct monthly random inspections of 5 doors to stairways and hazardous areas for 6 months to ensure they are self-closing or automatically closing with activation of the fire alarm system and that there are no devices impeding the self-closing device. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

2012 NFPA 99: 11.3.4 Signs 11.3.4.1 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. 11.3.4.2 The sign shall include the following wording as a minimum: CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING Based on observation and staff interview, the facility failed to ensure that Oxygen Storage Rooms contained the appropriate signage as required by NFPA 99, 2012 edition. This occurred in the Oxygen Storage Room near the Dentist office. The finding is: On 3/23/2018 between the hours of 8:40am and 3:30pm during the recertification survey, the following was observed: The main oxygen storage room located on the East Wing was noted to be lacking the correct signage. In an interview on 3/23/2018 at approximately 11:45am with the Director of Maintenance, he stated he can add the correct sign. 2012NFPA101 2012NFPA99

Plan of Correction: ApprovedApril 9, 2018

A precautionary sign containing the verbiage? CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING? was affixed to the doors of the Oxygen Storage Room near the Dentist office and the main Oxygen Storage Room located on the East Wing
The Director of Environmental Services / designee conducted an audit to ensure that doors to Oxygen Storage Rooms have a precautionary sign containing the verbiage? CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING? on them.
The Director of Environmental Services / designee will conduct monthly inspections of Oxygen Storage Rooms for 6 months to ensure they their doors have a precautionary sign containing the verbiage? CAUTION: OXIDIZING GAS(ES) STORED WITHIN NO SMOKING? on them. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.

K307 NFPA 101:INTERIOR WALL AND CEILING FINISH

REGULATION: Interior Wall and Ceiling Finish 2012 EXISTING Interior wall and ceiling finishes, including exposed interior surfaces of buildings such as fixed or movable walls, partitions, columns, and have a flame spread rating of Class A or Class B. The reduction in class of interior finish for a sprinkler system as prescribed in 10.2.8.1 is permitted. 10.2, 19.3.3.1, 19.3.3.2 Indicate flame spread rating(s). _____________________

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

2012 NFPA101: 10.2.4 Specific Materials. 10.2.4.1* Textile Wall and Textile Ceiling Materials. The use of textile materials on walls or ceilings shall comply with one of the following conditions: 1) Textile materials meeting the requirements of Class A when tested in accordance with ASTM E 84, Standard Test Method for Surface Burning Characteristics of Building Materials, or ANSI/UL 723, Standard for Test for Surface Burning Characteristics of Building Materials, using the specimen preparation and mounting method of ASTM E 2404, Standard Practice for Specimen Preparation and Mounting of Textile, Paper or Vinyl Wall or Ceiling Coverings to Assess Surface Burning Characteristics (see 10.2.3.4), shall be permitted on the walls or ceilings of rooms or areas protected by an approved automatic sprinkler system. (2) Textile materials meeting the requirements of Class A when tested in accordance with ASTM E 84 or ANSI/UL 723, using the specimen preparation and mounting method of ASTM E 2404 (see 10.2.3.4), shall be permitted on partitions that do not exceed three-quarters of the floor-to-ceiling height or do not exceed 8 ft (2440mm) in height, whichever is less. (3) Textile materials meeting the requirements of Class A when tested in accordance with ASTM E 84 or ANSI/UL 723, using the specimen preparation and mounting method of ASTM E 2404 (see 10.2.3.4), shall be permitted to extend not more than 48 in. (1220 mm) above the finished floor on ceiling-height walls and ceiling-height partitions. (4) Previously approved existing installations of textile material meeting the requirements of Class A when tested in accordance with ASTM E 84 or ANSI/UL 723 (see 10.2.3.4) shall be permitted to be continued to be used. (5) Textile materials shall be permitted on walls and partitions where tested in accordance with NFPA 265, Standard Methods of Fire Tests for Evaluating Room Fire Growth Contribution of Textile or Expanded Vinyl Wall Coverings on Full Height Panels and Walls. (See 10.2.3.7.) (6) Textile materials shall be permitted on walls, partitions, and ceilings where tested in accordance with NFPA 286, Standard Methods of Fire Tests for Evaluating Contribution of Wall and Ceiling Interior Finish to Room Fire Growth. (See 10.2.3.7.) 10.2.8.1 Other than as required in 10.2.4, where an approved automatic sprinkler system is installed in accordance with Section 9.7, Class C interior wall and ceiling finish materials shall be permitted in any location where Class B is required, and Class B interior wall and ceiling finish materials shall be permitted in any location where Class A is required. Based on observation and staff interview, the facility failed to ensure that interior wall finishes were either a Class A, Class B or Class C rating. This occurred on the 3rd floor of the facility. The finding is: On 3/23/2018 and 3/26/2018 between the hours of 8:40am and 3:30pm during the recertification survey, the following was observed: In the Holding Room on the 3rd floor, walls were lined with a wood, wainscoting material. The material measured approximately 3 feet in height from the base of the wall. The material covered every perimeter wall within the room. In a concurrent interview with the Director of Maintenance at approximately 10am, he stated the material has been there for a long time and he does not have any documentation verifying the rating. 2012 NFPA101 10NYCRR 711.2(a)(1)

Plan of Correction: ApprovedApril 9, 2018

The wood, wainscoting material in the Holding Room on the 3rd floor was removed and replaced with material that has a Class A flame spread rating.
The Director of Environmental Services / designee conducted an audit of interior walls to ensure that no other surfaces were lined with unrated wood material.
The Director of Environmental Services / designee will conduct monthly random inspections of 5 interior walls for 6 months to ensure that no other surfaces were lined with unrated wood material. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.

ROLES UNDER A WAIVER DECLARED BY SECRETARY

REGULATION: [(b) Policies and procedures. The [facilities] must develop and implement emergency preparedness policies and procedures, based on the emergency plan set forth in paragraph (a) of this section, risk assessment at paragraph (a)(1) of this section, and the communication plan at paragraph (c) of this section. The policies and procedures must be reviewed and updated at least every 2 years (annually for LTC).] At a minimum, the policies and procedures must address the following:] (8) [(6), (6)(C)(iv), (7), or (9)] The role of the [facility] under a waiver declared by the Secretary, in accordance with section 1135 of the Act, in the provision of care and treatment at an alternate care site identified by emergency management officials. *[For RNHCIs at §403.748(b):] Policies and procedures. (8) The role of the RNHCI under a waiver declared by the Secretary, in accordance with section 1135 of Act, in the provision of care at an alternative care site identified by emergency management officials.

Scope: Widespread
Severity: Potential to cause minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

Based on documentation review and staff interview, the facility failed to ensure that the facility had policies and procedures for the provision of care, if evacuating to a non-health care facility under a waiver declared by the Secretary. This was noted during review of the facility's Emergency Preparedness plan. The finding is: On 3/23/2018 and 3/26/2018 between the hours of 8:40am and 3:30pm during the Emergency Preparedness survey, the following was noted: Upon review of the facility's Emergency Preparedness documentation, it was revealed that the facility did not have a policy or procedure for the provision of care, if the facility needed to evacuate to an alternate care site under a waiver declared by the Secretary. In an interview with the Administrator at approximately 11am, he stated he is aware of the 1135 waiver, but does not have a policy or procedure relating to resident care at an alternate care site.

Plan of Correction: ApprovedApril 9, 2018

The Facilities Comprehensive Emergency Management Plan (CEMP) was updated to include procedures for the provision of care, if the facility needed to evacuate to an alternate care site.
The facility respectfully states that all residents were potentially affected.
The Administrator / designee will conduct a quarterly review of the Comprehensive Emergency Management Plan (CEMP) to ensure its compliance with the Facilities Role Under a Waiver Declared by the Secretary. Reviews with negative findings will have corrective actions taken.
Review findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Administrator is responsible for ensuring compliance.

ZT1N 713-1:STANDARDS OF CONSTRUCTION FOR NEW EXISTING NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: March 26, 2018
Corrected date: April 25, 2018

Citation Details

(I) All handwashing fixtures used by medical and nursing staff and food handlers shall be trimmed with valves that can be operated without the use of hands. Hand operated faucets may be fitted on lavatories in residents' rooms and residents' toilets. Based on observation and staff interview, the facility failed to ensure that hand washing sinks were trimmed with valves which could be operated without the use of hands. This was observed in the kitchen of the facility. The finding is: On 3/23/2018 and 3/26/2018 between the hours of 8:40am and 3:30pm during the recertification survey, the following was observed: The kitchen contained a hand washing sink. The sink could not be operated without the use of hands. In an interview on 3/23/2018 at approximately 12pm with the Director of Engineering, he stated he can install winged handles, similar to the ones on the other sinks.

Plan of Correction: ApprovedApril 9, 2018

The handwashing sink in the kitchen was replaced with winged handles which would allow it to be operated without the use of hands.
The Director of Environmental Services / designee conducted an audit to ensure that handwashing fixtures used by medical and nursing staff and food handlers are trimmed with valves that can be operated without the use of hands.
The Director of Environmental Services / designee will conduct monthly random inspections of 5 handwashing fixtures used by medical and nursing staff and food handlers for 6 months to ensure they are trimmed with valves that can be operated without the use of hands. Inspections with negative findings will have corrective actions taken.
Inspection findings will be presented to the Quality Assurance Committee at least quarterly for review and revisions to the action plan, if warranted.
The Director of Environmental Services is responsible for ensuring compliance.