Brooklyn United Methodist Church Home
July 28, 2017 Certification Survey

Standard Health Citations

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

REGULATION: (a) Infection prevention and control program. The facility must establish an infection prevention and control program (IPCP) that must include, at a minimum, the following elements: (1) A system for preventing, identifying, reporting, investigating, and controlling infections and communicable diseases for all residents, staff, volunteers, visitors, and other individuals providing services under a contractual arrangement based upon the facility assessment conducted according to §483.70(e) and following accepted national standards (facility assessment implementation is Phase 2); (2) Written standards, policies, and procedures for the program, which must include, but are not limited to: (i) A system of surveillance designed to identify possible communicable diseases or infections before they can spread to other persons in the facility; (ii) When and to whom possible incidents of communicable disease or infections should be reported; (iii) Standard and transmission-based precautions to be followed to prevent spread of infections; (iv) When and how isolation should be used for a resident; including but not limited to: (A) The type and duration of the isolation, depending upon the infectious agent or organism involved, and (B) A requirement that the isolation should be the least restrictive possible for the resident under the circumstances. (v) The circumstances under which the facility must prohibit employees with a communicable disease or infected skin lesions from direct contact with residents or their food, if direct contact will transmit the disease; and (vi) The hand hygiene procedures to be followed by staff involved in direct resident contact. (4) A system for recording incidents identified under the facility?s IPCP and the corrective actions taken by the facility. (e) Linens. Personnel must handle, store, process, and transport linens so as to prevent the spread of infection. (f) Annual review. The facility will conduct an annual review of its IPCP and update their program, as necessary.

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on observation and interview, during the Recertification survey, the facility did not ensure infection control practices were maintained. Specifically, a Certified Nursing Assistant (CNA) did not wash hands after providing resident care. This was evident for 1 of18 residents observed in Stage 2. (Resident #26). The finding is: Resident #26 is a resident with [DIAGNOSES REDACTED]. The Minimum Data Set 3.0 (MDS) assessment dated [DATE] documented the resident had moderately impaired cognition. The MDS further documented the resident required the total assist of 2 persons for bed mobility and transfer, On 7/26/17 at 11:15 AM, a hoyer lift transfer was observed for Resident #26. The resident was transfer was performed by two CNAs. The CNAs donned gloves prior to transferring the resident from bed into the wheelchair. CNA #1 assisted with positioning the resident's legs. She put the resident's slippers on adjusted the leg and foot rests. After she finished, CNA#1 removed her gloves and pushed the hoyer lift out of the room. She then returned to the room doorway and spoke to CNA #2. CNA #1 then bent down and lifted the cover to the clean linen cart to retrieve linens. The Surveyor stopped CNA #1 before she touched the clean linen. On 7/26/17 at 11:22 AM, CNA #1 was interviewed and stated she should have washed her hands after removing her gloves. She apologized and proceeded to wash her hands. On 7/27/17 at 10:59 AM, the Registered Nurse (RN) Supervisor was interviewed and stated all staff are in-serviced about infection control and handwashing. In addition, they have all been given personal hand sanitizers they can wear. She further stated the CNA should have washed her hands after removing the gloves when she completed the care. She stated staff would be in-serviced. 415.19(a)(1-3)

Plan of Correction: ApprovedAugust 22, 2017

I. Immediate Corrective Action
CNA #1 was in-serviced on appropriate infection control practices specifically related to Hand Hygiene by the Director of Nursing. 07/27/17
CNA #1 received a disciplinary warning for not following the prescribed hand washing protocol.07/27/17
II. Identify Other Residents
The RN Supervisor observed all CNA?s when transferring residents across all three shifts for one week and found that all CNA?s observed carried out appropriate Hand Hygiene protocols. The facility respectfully states that no other residents were affected by this practice. 08/24/17
III. Systemic Changes
The Director of Nursing reviewed the policy and procedure for hand hygiene and found same to be compliant. 08/11/17
The RN Supervisor(s) in-serviced all nursing staff across all three shifts on proper hand hygiene protocols. 07/27/17
Lesson plan and attendance will be filed for validation. 07/27/17
The DNS devised a uniform and standardized audit tool to monitor for compliance. DATE 08/11/17
IV. QA Monitoring
The DNS/Designee shall conduct the audits monthly for three (3) months and quarterly thereafter. Any negative findings will be corrected immediately by the DNS/Designee and reported to the Administrator. All findings will be reported quarterly at the QA Committee Meeting. 08/31/17
V. The DNS shall have overall responsibility to monitor for compliance. DATE 09/08/17

Standard Life Safety Code Citations

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the fire protection system for the cooking equipment was maintained in accordance with NFPA 96. Reference is made to the piping/nozzle system installed for the protection of cooking equipment in the kitchen that was not secured tightly so as to prevent accidental movement by hand. The findings include : On (MONTH) 25, (YEAR), between 10:00 AM to 2:30 PM, during the recertification survey, it was observed that the facility had installed a chemical type fire extinguishing system for the cooking equipment in the kitchen. The piping and nozzle system installed in connection with the extinguishing system was loosely installed so as to be easily moved by hand. All piping and nozzles installed in connection with the extinguishing system must be installed and maintained so as not to be moved by hand from their proper location, as pr NFPA 96. On (MONTH) 25 (YEAR) at approximately 11:00 AM, the facility's Director of Environmental Services stated that the fire suppression equipment company will be contacted to secure all loose piping and nozzles installed in connection with the fire suppression system for the cooking equipment, in the kitchen. 711.2 (a)(1) 2012 NFPA 101 1998 NFPA 96

Plan of Correction: ApprovedAugust 22, 2017

I. Immediate Corrective Action
In order to prevent the accidental movement by hand or otherwise, the piping/nozzle system for the cooking equipment at Brooklyn United Methodist Church Home was securely fastened on 8/3/17, by Mega Fire Protection Inc.08/3/17
II. Identification of Other Residents
Once the piping/nozzle was securely fastened, the deficient practice was resolved, and as there are no other fire protection systems for cooking equipment utilized or installed in the facility. The facility respectfully states that no other residents were affected by this practice. 08/3/17
III. Systemic Changes
The Environmental Service Director reviewed the policy & procedure for the fire suppression system for the cooking equipment in the kitchen and found same to be compliant.08/22/17
The Environmental Service Director in-serviced the maintenance and dietary staff on the protocol for the fire suppression system for the cooking equipment in the kitchen. 08/22/17
Lesson Plan and attendance filed for validation 08/22/17
The Environmental Service Director developed an audit tool to track compliance.08/22/17

IV. QA Monitoring
The Environmental Service Director/Designee shall conduct the audits monthly for four (4) months and quarterly thereafter. Any negative findings will be corrected immediately by maintenance and reported to the Administrator. All findings will be reviewed at the QA meetings quarterly. 08/31/17
The Environmental Service Director shall be responsible to monitor for overall compliance.
DATE 09/08/17

K307 NFPA 101:ELECTRICAL EQUIPMENT - TESTING AND MAINTENANC

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation, staff interview and record review, it was determined that the facility did not ensure that all electrical equipment used for resident care was maintained and tested in accordance with NFPA 99. Reference is made to the lack of documentation to show that the resident use electric beds, feeding pumps, oxygen concentrators were maintained and tested for safety as per manufacturer instructions and/or as per policies and protocols established by the facility or the contracted agency. The findings include: On (MONTH) 25, (YEAR) at 10:00 AM to 2:30 PM,during the annual recertification survey of the facility, it was observed that the facility had provided various resident care electrical equipment (electric beds, feeding pumps, oxygen concentrators) in resident rooms. An interview with the facility's Director of Environmental Services and review of facility maintenance records revealed that the facility lacked appropriate documentation to show that all resident care electrical equipment, including but not limited to the following, were maintained and tested in accordance with established policies and protocols. (1) In resident rooms, a number of oxygen concentrators lacked inspection/testing tags affixed to the equipment (as per facility policy), Examples were: concentrators in room #'s 412,417,and 413. (2) In resident rooms, a number of feeding pumps lacked inspection/testing tags or labels. Examples were: room #'s 317, 418, 413 and 419. (3) The facility had provided electric operated beds in resident rooms (InVacare or GF Health beds). The beds lacked any affixed inspection/testing tags or the facility had no documentation to show that all electrical beds were tested /inspected for safety as per established intervals. On (MONTH) 25,2017, at approximately 12:00 PM,the facility's Director of Environmental Services stated that the contracted company for the maintenance of concentrators,beds and other electrical equipment will be contacted to provide appropriate inspection/testing, tags/labels for all electrical equipment as per established intervals. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedAugust 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. The maintenance department inspected, tested , and conducted maintenance where necessary to the oxygen concentrators located in rooms [ROOM NUMBER], and documented the inspection, testing and maintenance that was conducted as per manufacturer?s recommendations in a log book established for patient care related electrical equipment.08/22/17
2. The maintenance department inspected, tested , and conducted maintenance where necessary to the feeding pumps located in rooms 317, 418, 413, and 419 and documented the inspection, testing, and maintenance that was conducted as per manufacturer?s recommendations in a log book established for patient care related electrical equipment.08/22/17
3. The maintenance department inspected, tested , and conducted maintenance where necessary to ALL the electric beds (Invacare or GF Health Beds) in the facility, and documented the inspection, testing, and maintenance that was conducted as per manufacturer?s recommendations in a log book established for patient care related electrical equipment.08/22/17
II. Identification of Other Residents
1. The Environmental Service Director inspected all concentrators in the facility. Any other oxygen concentrator identified upon inspection would be immediately tested , inspected, and maintained according to manufacturer?s recommendations and logged into a patient care related electrical equipment log book. No other oxygen concentrators were identified as being affected by this practice. The facility respectfully states that no other residents were affected by this practice.08/22/17
2. The Environmental Service Director inspected all the feeding pumps in the facility. Any other feeding pumps identified upon inspection would be immediately tested , inspected and maintained according to manufacturer?s recommendations and logged into a patient care related electrical equipment log book. No other feeding pumps were identified as being affected by this practice. The facility respectfully states that no other residents were affected by this practice. 08/22/17
3. Once the maintenance department inspected, tested , and conducted maintenance where necessary to all electric beds and documented into the patient care related electrical equipment log book, no other residents were affected by this practice.08/22/17
III. Systemic Changes
The Environmental Service Director reviewed the policy and procedure for testing and maintenance of patient care related electrical equipment and revised the policy to incorporate that the testing and maintenance is conducted in accordance with NFPA 101, 10.3. 08/08/17
The Environmental Service Director in-serviced all maintenance staff on the revised protocol, specified related to testing and maintenance of Patient Care Related Electrical Equipment.08/22/17
The Environmental Service Director developed an audit to track compliance. 08/22/17
IV. QA Monitoring
The Environmental Service Director/Designee shall conduct the audits monthly for four (4) months and quarterly thereafter. Any negative findings will be corrected immediately by maintenance and reported to the Administrator. All audit findings will be reviewed at the QA meetings.08/31/17
The Environmental Service Director shall be responsible for monitoring overall compliance. 09/08/17

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: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation and record review, it was determined that the facility did not ensure that the emergency power generating equipment was being tested under load 12 times a year. Reference is made to the lack of documentation to show that the generator was tested under load at least 12 times a year. The findings include: On (MONTH) 25,2017 between 10:00 AM and 2:30 PM during the recertification survey, it was observed that the facility had installed emergency power generating equipment (generator) on the first floor. A review of the facility maintenance and testing records revealed that the facility had not tested the generator under load at least 12 times a year. The facility had no documentation to show that the generator was tested under load in (YEAR). On (MONTH) 25,2017, at approximately 1:45 PM, the facility's Director of Environmental Services stated that the generator was only exercised weekly without load by the maintenance department. The Director further stated that the person in charge of the generator will be instructed to test generator under load at least 12 times a year and keep records of such tests. 711.2 (a)(1) 2012 NFPA 101 2012 NFPA 99

Plan of Correction: ApprovedAugust 22, 2017

I. Immediate Corrective Action
The emergency generator was exercised under load on 8/17/17 by the maintenance department, and documentation was entered into a log indicating that a full load test was conducted.08/17/17
II. Identification of Other Residents
Once the full load test was conducted by the maintenance department and documented into the log book, no other residents were affected by this practice.08/17/17
III. Systemic Changes
The Environmental Service Director reviewed the policy and procedure for Testing the Emergency Generator Under Load and found same to be compliant.08/22/17.
The environmental Service Director in-serviced all maintenance staff on the requirements for maintenance and testing of essential electrical systems. 08/22/17
Lesson Plan and attendance filed for validation. 08/22/17
The Environmental Service Director developed an audit tool was developed to track compliance.08/22/17
IV. QA Monitoring
The Environmental Service Director/Designee shall conduct the audits monthly for one (1) year. Any negative findings will be corrected immediately by maintenance and reported to the Administrator.
All findings will be reviewed at the QA meetings quarterly.08/31/17
The Environmental Service Director shall be responsible to monitor for overall compliance. 09/08/17

K307 NFPA 101:SMOKE DETECTION

REGULATION: Smoke Detection 2012 EXISTING Smoke detection systems are provided in spaces open to corridors as required by 19.3.6.1. 19.3.4.5.2

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation, it was determined that the facility did not ensure that the spaces open to the corridor were provided with smoke detection system, as per 19.3.6.1. Reference is made to the vending machine room and the lounge area that were open to the corridor with no smoke detection system installed in these areas The findings include: On (MONTH) 25, (YEAR) at 10:00 AM to 2:30 PM, during the recertification survey of the facility, it was observed that the vending machine room and the lounge area, located on the first floor,were open to the corridor. The vending machine room and the lounge area lacked the smoke detection system as per 19.3.6.1 On (MONTH) 25, (YEAR) at approximately 1:00 PM, the facility's Director of Environmental Services stated that smoke detectors will be installed in all open spaces to the corridor. 711.2 (a)(1) 2012 NFPA 101

Plan of Correction: ApprovedAugust 22, 2017

I. Immediate Corrective Action
On 8/2/17, Alburdan Electric Inc. installed two smoke detectors in the area(s) that were open to the corridor. One was installed in the lounge area and the other was installed in the vending machine room.08/2/17
II. Identification of Other Residents
The Environmental Service Director inspected the entire facility and found that all other areas open the corridor(s) were compliant with 19.3.6.1 (smoke detectors installed).
The facility respectfully states that no other residents were adversely affected by this practice.08/3/17
III. Systemic Changes
The Environmental Service Director reviewed the policy and procedure on Life Safety Code 19.3.6.1 (spaces open to corridor are provided with smoke detection systems), and found same to be compliant.
The Environmental Service Director in-serviced all maintenance staff on Life Safety Code 19.3.6.1 on 08/22/17
Attendance and Lesson Plan filed for validation.
The Environmental Service Director developed an audit tool to monitor for compliance.

IV. QA Monitoring
The Environmental Service Director/Designee will conduct the audits monthly for four (4) months and quarterly thereafter. Any negative finding will be corrected immediately by maintenance and reported to the Administrator.
All findings will be reviewed at the QA Meetings quarterly. 08/31/17
The Environmental Service Director shall be responsible for overall compliance by
DATE 09/08/17

K307 NFPA 101:SPRINKLER SYSTEM - INSTALLATION

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

Scope: Pattern
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

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. Reference is made to the lack of sprinklers in a number of areas in the building. Examples include: the first floor kitchen closet lacked sprinklers; obstructed sprinkler in the sprinkler room; a sprinkler was not installed within six feet of the wall in the housekeeping storage room and the main electric panel room that had stored items. The findings include: On (MONTH) 25, (YEAR) between 10:00 AM and 2:30 PM during the recertification survey, it was observed that a number of areas in the building, including but not limited to the following areas, lacked sprinklers, or the existing sprinklers were obstructed so as not to provide coverage for the entire protected area : (1) On the first floor, the storage closet off the kitchen area lacked sprinklers. (2) In the main sprinkler room, the sprinkler head was obstructed by the ventilation duct system, i.e. the sprinkler head was abutted against the duct. (3) In the housekeeping storage room on the first floor, the sprinkler was not installed within six feet of the wall. The sprinkler was approximately 12 feet from the wall. (4) The main electric panel room on the first floor lacked sprinklers. The room was being used for the storage of a motorized snow blower, and other miscellaneous items. On (MONTH) 25, (YEAR) at approximately 12:30 PM, the facility's Director of Environmental Services stated that the sprinkler company will be contacted to provide sprinkler in all areas of the building in accordance with NFPA 13. 711. 2 (a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedAugust 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
1. A sprinkler head was installed by [MEDICATION NAME] Fire Protection Service Corp. on 8/3/17, in the first floor storage closet off the kitchen area.08/3/17
2. The sprinkler head in the main sprinkler room was moved on 8/3/17 by [MEDICATION NAME] Fire Protection Service Corp. 28 inches from the ventilation duct system so the sprinkler head would NOT BE obstructed.08/3/17
3. The sprinkler head in the housekeeping storage room was moved on 8/3/17 by [MEDICATION NAME] Fire Protection Service Corp. so that IT IS within six (6) feet of the wall.08/3/17
4. The snow blower and other miscellaneous items that were stored in the main electrical panel room have been removed and stored elsewhere in the facility on 7/27/17 by the maintenance staff.07/27/17
II. Identification of Other Residents
1. The Environmental Service Director inspected the entire facility and once the sprinkler head was installed on 8/3/17 in the first floor storage closet off the kitchen area, no other residents were affected by this practice. 08/3/17
2. The Environmental Service Director inspected the entire facility and once the sprinkler head in the main sprinkler room was moved on 8/3/17, no other residents were affected by this practice.08/3/17
3. The Environmental Service Director inspected the entire facility and once the sprinkler head in the housekeeping storage room was moved on 8/3/17, no other residents were affected by this practice.08/3/17
4. The Environmental Service Director inspected the electrical panel room and once the stored equipment was moved on 7/27/17, no other residents were affected by this practice.
III. Systemic Changes
1. The Environmental Service Director reviewed the policy & procedure on Standards for Installation of Sprinkler Systems and found same to be compliant.08/18/17
The maintenance staff was in-serviced and lesson plan and attendance are filed for validation:08/18/17
2. The Environmental Service Director reviewed the policy & procedure on Standards for Installation of Sprinkler Systems and found same to be compliant.08/18/17
The maintenance staff was in-serviced and lesson plan and attendance are filed for validation:08/18/17
3. The Environmental Service Director reviewed the policy & procedure on Standards for installation of Sprinkler Systems and found same to be compliant.08/18/17
The maintenance staff was in-serviced and lesson plan and attendance are filed for validation:08/18/17
4. The Environmental Service Director reviewed the policy & procedure on Standards for Installation of Sprinkler Systems and found same to be compliant.08/18/17
The maintenance staff was in-serviced and lesson plan and attendance are filed for validation:08/18/17
The Environmental Service Director developed an audit tool to monitor for compliance with items 1, 2, 3, and 4 DATE 08/22/17
IV. QA Monitoring
The Environmental Service Director/Designee shall conduct the audits monthly for four (4) months and quarterly thereafter. Any negative findings will be corrected immediately by maintenance and reported to the Administrator. All findings will be reviewed at the QA meetings quarterly. 08/31/17
V.The Environmental Service Director shall be responsible to monitor for overall compliance.
DATE 09/08/17

K307 NFPA 101:SPRINKLER SYSTEM - MAINTENANCE AND TESTING

REGULATION: Sprinkler System - Maintenance and Testing Automatic sprinkler and standpipe systems are inspected, tested, and maintained in accordance with NFPA 25, Standard for the Inspection, Testing, and Maintaining of Water-based Fire Protection Systems. Records of system design, maintenance, inspection and testing are maintained in a secure location and readily available. a) Date sprinkler system last checked _____________________ b) Who provided system test ____________________________ c) Water system supply source __________________________ Provide in REMARKS information on coverage for any non-required or partial automatic sprinkler system. 9.7.5, 9.7.7, 9.7.8, and NFPA 25

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Based on observation it was determined that the facility did not ensure that the automatic sprinklers were maintained in accordance with NFPA 13. Reference is made to the lack of cover plates for the concealed sprinklers in the corridors in the vicinity of the main dining room and lobby area on the first floor. The findings include: On (MONTH) 25, (YEAR) between 10:00 AM and 2:30 PM during the recertification survey, it was observed that cover plates were lacking for a number of concealed sprinklers in the corridors in the vicinity of the main dining room and in lobby area of the first floor. On (MONTH) 25,2017, at approximately 11:45 AM, the facility's Director of Environmental Services stated that the sprinkler company will be contacted to provide cover plates for all concealed sprinklers. 711.2 (a)(1) 2012 NFPA 101 2010 NFPA 13

Plan of Correction: ApprovedAugust 22, 2017

**NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** I. Immediate Corrective Action
On 8/3/17 [MEDICATION NAME] Fire Protection Service Corp. installed the cover plates for the concealed sprinklers in the vicinity of the main dining room and in the lobby area of the first floor.08/3/17
II. Identification of Other Residents
The Environmental Service Director inspected all areas in the entire facility and all other concealed sprinklers were covered appropriately.08/3/17
The facility respectfully states that no other residents were affected by this practice.
III. Systemic Changes
The Environmental Service Director reviewed the policy and procedure for Sprinkler Service Maintenance and Testing and found same to be compliant. 08/21/17
The maintenance staff was in-serviced on the policy and procedure, lesson plan and attendance are filed for validation. 08/21/17
An audit tool was developed by the Environmental Service Director to track compliance.08/21/17
IV. QA Monitoring
The Environmental Service Director/Designee shall conduct the audits monthly for four (4) months and quarterly thereafter. Any negative findings will be corrected immediately by maintenance and reported to the Administrator. All findings will be reviewed at the QA meetings quarterly.08/31/17
The Environmental Service Director shall be responsible to monitor for overall compliance.09/08/17

ZT1N 713-2:STANDARDS OF CONSTRUCTION FOR NEW NH

REGULATION: N/A

Scope: Isolated
Severity: Potential to cause more than minimal harm
Citation date: July 28, 2017
Corrected date: September 8, 2017

Citation Details

Physical Plant Violation - Stated Only NYCRR 713-2.5 (c)(6) (6) A soiled workroom that contain a clinical sink or equivalent flushing rim fixture, a sink equipped for handwashing, work counter, waste receptacle,and linen receptacle or a soiled holding room that is part of an approved system for collection and disposal of soiled materials. The soiled holding room and shall be similar to the soiled workroom except that the clinical sink and work counter may be omitted. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that work counters were provided in all soiled workrooms. Reference is made to the lack of work counters in the soiled workrooms on the 2nd, 3rd, and 4th floors. The findings include: On (MONTH) 25, (YEAR) at 10:00 AM to 2:30 PM, it was observed that facility had provided a soiled workroom on each nursing unit. The soiled workrooms on the 2nd, 3rd and 4th floors lacked work counters. On (MONTH) 25, (YEAR) at approximately 12:15 PM, the facility's Director of Environmental Services stated that work counters will be installed in all soiled workrooms. NYCRR 713-2.21 (e)(2) (iii) Backflow preventers (vacuum breakers) shall be installed on hose bibbs, janitor's sinks, bed pan flushing attachments and on all other fixtures to which hoses or tubings can be attached. This requirement is not met as evidenced by: Based on observation, it was determined that the facility did not ensure that backflow preventers (vacuum breakers) were installed on all water fixtures to which hoses could be attached. Reference is made to the water fixtures with attached hoses isntalled in the tubroom/shower rooms on the 2nd, 3rd, and 4th floors. The findings include: On (MONTH) 25, (YEAR) at 10:00 AM to 2:30 PM, it was observed that the water fixtures installed in the tubroom/shower rooms had hoses attached to them. However, the water fixtures with attached hoses lacked backflow preventers (vacuum breakers) in the tubroom/shower rooms on the 2nd,3rd, and 4th floors.

Plan of Correction: ApprovedAugust 22, 2017

I. Immediate Corrective Action
The maintenance department installed work counters in each of the soiled work rooms on floors 2,3,&4. 08/3/17
II. Identification of Other Residents
Once the maintenance department installed the work counters in each of the soiled work rooms, no other residents were affected by this practice, as the facility only has three (3) soiled work rooms.08/3/17
III. Systemic Changes
The Environmental Service Director reviewed the policy and procedure for soiled work rooms, and found same to be compliant.08/22/17
The maintenance staff was in-serviced on this policy and protocol for soiled work rooms.08/23/17
Lesson plan and attendance filed for validation.08/23/17
The Environmental Service Director developed an audit tool to track compliance.08/23/17
IV. QA Monitoring
The Environmental Service Director/Designee will conduct the audits monthly for three (3) months and quarterly thereafter.08/31/17
Any negative findings will be corrected immediately by maintenance and reported to the Administrator.08/31/17
All findings will be reviewed at the QA meetings quarterly.08/31/17
The Environmental Service Director shall have the overall responsibility to monitor for compliance.09/08/17